Nursing Elites

1. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

• A. Aligning a trochanter wedge between the client's legs.
• B. Placing a towel roll under the client's neck.
• C. Applying an orthotic to the client's foot.
• D. Positioning a pillow under the client's knees.

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

2. What are the signs of hypoglycemia, and how should a healthcare provider respond to a patient experiencing this condition?

• A. Shakiness or Tremors
• B. Confusion or Irritability
• C. Hunger
• D. Dizziness or Lightheadedness

Correct answer: A

Rationale: The signs of hypoglycemia include shakiness, confusion, hunger, dizziness, and lightheadedness. However, the classic and most common early sign is shakiness or tremors. When a patient is experiencing hypoglycemia, a healthcare provider should respond promptly by administering glucose to raise the blood sugar levels. Choice A is correct as it directly addresses one of the primary signs of hypoglycemia. Choices B, C, and D are incorrect because while confusion, irritability, hunger, dizziness, and lightheadedness can also be signs of hypoglycemia, shakiness or tremors are the classic and most common early symptoms that healthcare providers should be particularly vigilant for.

3. What are the principles of aseptic technique in wound care?

• A. Use sterile gloves and a clean dressing
• B. Apply a clean dressing using sterile scissors
• C. Wash hands thoroughly before applying the dressing
• D. Use a clean glove and avoid contact with the wound

Correct answer: A

Rationale: The correct answer is A: 'Use sterile gloves and a clean dressing.' Aseptic technique in wound care requires the use of sterile gloves to prevent infection. Choice B is incorrect as the method of application does not primarily focus on maintaining asepsis. Choice C, while important for infection control, is not specific to aseptic technique in wound care. Choice D is incorrect because using a single clean glove does not ensure the level of sterility needed for aseptic wound care.

4. A nurse is teaching a client who is to undergo radiation therapy for breast cancer about potential adverse effects. Which of the following adverse effects should the nurse include in the teaching?

• A. Fatigue
• B. Constipation
• C. Hair loss
• D. Weight gain

Correct answer: A

Rationale: The correct adverse effect that the nurse should include in the teaching is fatigue. Fatigue is a common side effect of radiation therapy, particularly with prolonged treatment. Constipation, hair loss, and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices. Fatigue can significantly impact a patient's quality of life during treatment and should be addressed proactively by healthcare providers.

5. A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

• A. High blood pressure
• B. Decreased bowel sounds
• C. Constipation
• D. Difficulty urinating

Correct answer: D

Rationale: The correct answer is 'Difficulty urinating.' This finding is crucial to report promptly as it can indicate a complication, such as urinary retention or injury to the urinary tract, which are significant concerns post-hernia surgery. High blood pressure (Choice A) may require monitoring but is not as urgent as difficulty urinating. Decreased bowel sounds (Choice B) and constipation (Choice C) are common after surgery and may resolve with appropriate interventions but are not as critical as addressing difficulty urinating.

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