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. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose level of 120 mg/dL
• B. White blood cell count of 8,000/mm³
• C. Temperature of 37.2°C (99°F)
• D. Daily weight increase of 0.45 kg (1 lb)

Correct answer: D

Rationale: The correct answer is D. A sudden weight increase may indicate fluid retention, a complication of TPN therapy that should be reported. Options A, B, and C are within normal ranges and do not directly relate to TPN therapy complications. A blood glucose level of 120 mg/dL is normal, a white blood cell count of 8,000/mm³ is within the normal range, and a temperature of 37.2°C (99°F) is also normal.

3. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

4. What are the signs of hypovolemic shock and what is the nurse's role in management?

• A. Rapid pulse, low blood pressure; administer IV fluids
• B. Cold extremities, rapid breathing; administer oxygen
• C. Decreased urine output, sweating; administer diuretics
• D. Weak pulse, clammy skin; administer vasopressors

Correct answer: A

Rationale: The correct signs of hypovolemic shock are a rapid pulse and low blood pressure. Administering IV fluids helps to restore circulating volume, which is essential in managing hypovolemic shock. Choice B is incorrect because cold extremities and rapid breathing are not typical signs of hypovolemic shock. Choice C is incorrect as administering diuretics would further decrease circulating volume, worsening the condition. Choice D is incorrect as administering vasopressors may further compromise perfusion in hypovolemic shock.

5. A healthcare professional is reviewing the medical record of a client who underwent surgery for a hip fracture. Which of the following findings should the healthcare professional report to the provider?

• A. Clear lung sounds
• B. Fever
• C. Pain in the operative leg
• D. Capillary refill of 2 seconds

Correct answer: B

Rationale: The correct answer is B: Fever. Fever in a postoperative client can indicate an infection, which is a serious complication and should be reported immediately to the provider for further evaluation and management. Clear lung sounds (Choice A) are a positive finding indicating normal respiratory function. Pain in the operative leg (Choice C) is expected postoperatively and should be managed with appropriate pain relief measures. Capillary refill of 2 seconds (Choice D) is within the normal range (less than 3 seconds) and is not a concerning finding postoperatively.

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