Nursing Elites

1. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?

• A. Use the cane on the weak side of the body
• B. Advance the cane and the strong leg simultaneously
• C. Maintain two points of support on the floor
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: C

Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the 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. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

• A. The institution's restraints/seclusion policies
• B. The patient's competence
• C. The patient's voluntary/involuntary status
• D. The patient's nursing care plan

Correct answer: C

Rationale: The correct answer is C because the patient's voluntary or involuntary status should not impact the nurse's actions when using restraints. The use of restraints should be based on the patient's behavior and the need to ensure their safety and the safety of others. Choices A, B, and D are important factors that should influence the nurse's actions. The institution's restraints/seclusion policies provide guidelines on the appropriate use of restraints, the patient's competence helps determine their understanding and ability to control their behavior, and the patient's nursing care plan guides the overall care provided, including the use of restraints if necessary.

3. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?

• A. Nausea
• B. Confusion about own name
• C. Rapid pulse
• D. Vomiting

Correct answer: B

Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.

4. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

• A. Encourage the client to eat high-protein foods
• B. Encourage the client to drink 2 liters of fluid daily
• C. Instruct the client to use a soft toothbrush
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

5. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.
• D. Set up the sterile field 5 cm (2 in) above waist level.

Correct answer: A

Rationale: To maintain the sterility of the field, the nurse should place the cap from the solution sterile side up on a clean surface. This action helps prevent contamination. Choice B is incorrect because opening the outermost flap toward the body increases the risk of introducing contaminants onto the sterile field. Choice C is incorrect as the sterile dressing should be placed at least 2.5 cm (1 in) from the edge of the sterile field to prevent accidental contamination. Choice D is incorrect because setting up the sterile field above waist level could lead to inadvertent contact and compromise the field's sterility.

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