Nursing Elites

1. A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?

• A. Steamed carrots
• B. Orange slices
• C. Mashed potatoes
• D. Baked chicken

Correct answer: B

Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.

2. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?

• A. Flush the IV line with saline
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.

3. When teaching a client about the correct use of a cane, what should the nurse include?

• A. Hold the cane on the weaker side
• B. Ensure the cane has a rubber tip
• C. Keep the cane on the dominant side
• D. Use the cane only on stairs

Correct answer: B

Rationale: The correct answer is B. When instructing a client on the use of a cane, it is essential to ensure that the cane has a rubber tip. This rubber tip helps prevent slipping, providing additional stability and safety. Option A, holding the cane on the weaker side, is incorrect as the cane should be held on the stronger side to provide better balance and support. Option C, keeping the cane on the dominant side, is also incorrect because the cane should be held on the stronger side. Option D, using the cane only on stairs, is not comprehensive as the cane can be used for support and balance while walking on level ground as well.

4. A nurse is preparing to transfer a client from a bed to a chair. The client can bear partial weight and has upper body strength. What device should the nurse use?

• A. Mechanical lift
• B. Gait belt
• C. Slide board
• D. Stand-assist lift

Correct answer: D

Rationale: A stand-assist lift is the correct choice in this scenario. This device is suitable for clients who can bear partial weight and have upper body strength, as it allows them to actively participate in the transfer process. A mechanical lift is typically used for clients who are non-weight bearing or have limited mobility. A gait belt is used for providing support and stability during walking or transferring short distances. A slide board is used for transferring clients who are unable to bear weight and need assistance moving from one surface to another.

5. A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?

• A. Increase fiber intake
• B. Encourage the client to walk daily
• C. Use a stool softener as needed
• D. Use a laxative daily

Correct answer: A

Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice C) and using a laxative daily (choice D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.

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