Nursing Elites

1. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?

• A. Use the cane on the stronger side of the body
• B. Maintain two points of support on the floor at all times
• C. Advance the cane and the strong leg together
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

2. A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse take?

• A. Use the Z-track method to administer the medication.
• B. Use a 1.5-inch needle to administer the medication.
• C. Use the deltoid muscle for the injection.
• D. Administer the injection at a 90° angle.

Correct answer: A

Rationale: The Z-track method should be used to administer IM injections in obese clients to prevent medication from leaking into subcutaneous tissue. Using a longer needle (1.5 inches) ensures that the medication reaches the muscle mass adequately. Choice C is incorrect because the deltoid muscle is not ideal for IM injections in obese clients due to inadequate muscle mass. Administering the injection at a 90° angle (perpendicular to the skin) is recommended for IM injections to ensure proper delivery into the muscle.

3. What are the early signs of hypoglycemia in a diabetic patient?

• A. Sweating and trembling
• B. Confusion and irritability
• C. Dizziness and increased heart rate
• D. Nausea and vomiting

Correct answer: A

Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.

4. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

• A. I will let the client know that I am available as the interpreter.
• B. I will receive a small fee for interpreting for this client.
• C. I am glad I am available today, but when I am not, you can use a family member.
• D. I will let the client know that an interpreter is unavailable during the night shift.

Correct answer: A

Rationale: Choice A is correct because the nurse should inform the client of their availability to interpret, ensuring that communication is clear and culturally appropriate. Choice B is incorrect as interpreters in healthcare settings usually do not receive fees for providing interpretation services. Choice C is incorrect because suggesting the use of a family member as an interpreter may not ensure accurate communication, as they may not be trained or impartial. Choice D is incorrect because stating that an interpreter is unavailable during the night shift does not address the current situation where the nurse has agreed to interpret for the client.

5. What should the nurse do first when a client with a tracheostomy exhibits respiratory distress?

• A. Notify the provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct initial action when a client with a tracheostomy exhibits respiratory distress is to suction the tracheostomy. This helps to clear secretions and improve the client's ability to breathe. Notifying the provider (choice A) can cause a delay in immediate intervention. Administering a bronchodilator (choice C) may be necessary but is not the priority in this situation. Increasing the oxygen flow rate (choice D) can be helpful but should come after addressing the immediate need for suctioning to clear the airway.

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