Nursing Elites

1. A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?

• A. Use the cane on the stronger side
• B. Advance the cane and the weaker leg at the same time
• C. Use the cane on the weaker side
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.

2. What is the role of the nurse in postoperative care for a patient with a hip replacement?

• A. Monitor for signs of infection and administer pain relief
• B. Ensure the patient follows a low-calcium diet
• C. Ensure the patient uses crutches to avoid pressure on the hip
• D. Monitor for signs of deep vein thrombosis

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of infection and administer pain relief. In postoperative care for a patient with a hip replacement, it is crucial for the nurse to monitor for signs of infection, such as increased pain, redness, swelling, or drainage from the surgical site. Administering pain relief is also important to ensure the patient's comfort and aid in their recovery. Choices B, C, and D are incorrect as they do not directly relate to the immediate postoperative care needs of a patient with a hip replacement. Ensuring a low-calcium diet, using crutches, or monitoring for deep vein thrombosis are not primary responsibilities in the immediate postoperative period for this type of surgery.

3. A client undergoing bariatric surgery is being taught about postoperative dietary changes by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will drink carbonated beverages after surgery
• B. I will eat large meals after surgery
• C. I will avoid consuming solid foods for several weeks
• D. I will avoid taking small sips of liquids

Correct answer: C

Rationale: The correct answer is C because avoiding solid foods after bariatric surgery is crucial to prevent complications and promote healing. Choice A is incorrect as carbonated beverages can cause discomfort and should be avoided. Choice B is incorrect as large meals are not suitable after bariatric surgery. Choice D is incorrect as taking small sips of liquids is encouraged to prevent dehydration and promote recovery.

4. A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?

• A. Take this medication in the morning.
• B. Avoid drinking grapefruit juice.
• C. Increase your intake of leafy green vegetables.
• D. Monitor your pulse daily while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Avoid drinking grapefruit juice.' Grapefruit juice can increase the risk of toxicity when taken with simvastatin. Instructing the client to avoid grapefruit juice helps prevent this interaction. Choice A is incorrect because the timing of medication administration for simvastatin is usually in the evening. Choice C is unrelated to simvastatin therapy. Choice D is not necessary for monitoring while taking simvastatin.

5. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?

• A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
• B. Reinforcing teaching with a client who is learning to walk with a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure ulcer

Correct answer: C

Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.

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