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 teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

• A. Soak feet in hot water daily
• B. Use a heating pad on the feet daily
• C. Cut toenails straight across
• D. Massage feet with lotion daily

Correct answer: C

Rationale: The correct answer is C: 'Cut toenails straight across.' This instruction is crucial for clients with diabetes to prevent ingrown toenails and potential foot complications. Soaking feet in hot water daily (Choice A) can lead to skin damage and is not recommended for diabetic individuals. Using a heating pad on the feet daily (Choice B) can cause burns or injuries due to reduced sensation in the feet that often accompanies diabetes. Massaging feet with lotion daily (Choice D) is generally safe but may not address the specific preventive measure of cutting toenails correctly.

3. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client with pneumonia who had new onset of confusion
• B. A client with diabetes who had low blood sugar overnight
• C. A client with a leg fracture who needs pain medication
• D. A client whose urinary output was 100 mL for the past 12 hours

Correct answer: A

Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.

4. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

• A. WBC count 2,900 /mm3.
• B. Fasting blood glucose 100 mg/dl.
• C. Hgb 14 g/dl.
• D. Heart rate 58/min.

Correct answer: A

Rationale: A WBC count of 2,900/mm3 indicates leukopenia, which is a serious side effect of clozapine and contraindicates its use. Leukopenia is a significant concern with clozapine therapy due to the risk of agranulocytosis, a potentially life-threatening condition. Monitoring the WBC count is crucial to detect this adverse effect early. The other options (B, C, and D) are within normal ranges and not contraindications for administering clozapine.

5. A healthcare professional is caring for a client with coronary artery disease (CAD) who is prescribed aspirin. Which of the following findings should the healthcare professional report to the provider?

• A. A history of gastrointestinal bleeding
• B. A history of hypertension
• C. A platelet count of 180,000/mm³
• D. A prothrombin time (PT) of 12 seconds

Correct answer: A

Rationale: The correct answer is A: A history of gastrointestinal bleeding. Patients with a history of gastrointestinal bleeding are at increased risk of complications when taking aspirin due to its effects on platelet function and the gastrointestinal tract. Reporting this finding to the provider is crucial to ensure patient safety. Choices B, C, and D are not directly related to the increased risk associated with aspirin use in patients with a history of gastrointestinal bleeding, making them less relevant in this scenario. While monitoring platelet count and PT are important in patients taking aspirin, a history of gastrointestinal bleeding takes precedence as it directly impacts the safety and effectiveness of aspirin therapy in this client.

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