Nursing Elites

1. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?

• A. Take off shoes while in the house and wear only socks
• B. Limit activities to the lower level of the home
• C. Keep a lamp near the door of every room
• D. Install non-slip pads in the shower or bathtub

Correct answer: D

Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.

2. A urine pregnancy test:

• A. May be negative even if a blood pregnancy test is positive.
• B. Is positive only during the first trimester of pregnancy.
• C. Will be negative if the amount of LH isn't enough to meet or exceed the sensitivity of the testing device.
• D. All of the above.

Correct answer: A

Rationale: A urine pregnancy test detects HCG in a pregnant woman's urine. Blood levels of HCG are usually higher and register earlier than HCG levels in the urine. Choice A is correct because urine pregnancy tests may be negative even if a blood pregnancy test is positive due to the differences in HCG levels in blood and urine. Choice B is incorrect because a urine pregnancy test can be positive throughout pregnancy, not just in the first trimester. Choice C is incorrect because LH (luteinizing hormone) is not the hormone detected in a pregnancy test; it is HCG (human chorionic gonadotropin). Choice D is incorrect because not all the statements provided are true.

3. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

• A. The skin on the arm appears mottled
• B. The cold pack has been in place for 10 minutes
• C. The client complains of feeling nauseated
• D. The capillary refill in the area distal to the arm is 2 seconds

Correct answer: A

Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.

4. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

• A. Wait 30 minutes if the patient has ingested hot or iced liquids.
• B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
• C. Shake the glass thermometer down to 35.5�C before taking the patient's temperature.
• D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5�C, not 37.5�C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer. Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.

5. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?

• A. Collaborating with the client to establish healthcare goals
• B. Reviewing the client's medical record history
• C. Explaining the purpose of administered medications to the client
• D. Rapidly resetting priorities for client care based on changes in the client's condition

Correct answer: D

Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.

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