Nursing Elites

1. A client has a new prescription for a cane. What instruction 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 instruction the nurse should include is to ensure the cane has a rubber tip. This is important as it prevents slipping and ensures safety while walking. Choice A is incorrect because the cane should be held on the stronger side to provide better support. Choice C is incorrect as the cane should be used on the stronger, not the dominant, side for stability. Choice D is incorrect because a cane can be used for support in various situations, not just on stairs.

2. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

• A. Nutritional status
• B. Client's response to pain medication
• C. Daily vital signs
• D. Most recent lab results

Correct answer: B

Rationale: The correct answer is B: Client's response to pain medication. When transferring a client to another unit, it is crucial to communicate how the client is responding to pain medication to ensure continuity of care and appropriate pain management. While nutritional status, daily vital signs, and most recent lab results are important aspects of the client's care, the client's response to pain medication directly impacts their comfort and well-being during the transfer process.

3. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Apply a heating pad to the wound
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

4. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?

• A. Apply a cold compress
• B. Discontinue the IV line
• C. Elevate the limb
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.

5. When teaching about safety risks for adolescents, what should the nurse emphasize?

• A. Adolescents have a decreased risk of injury
• B. Peer pressure can lead to risky behaviors
• C. Increased responsibility reduces risks
• D. Adolescents are less likely to engage in substance abuse

Correct answer: B

Rationale: The correct answer is B: 'Peer pressure can lead to risky behaviors.' Adolescents are at an increased risk for injury due to peer pressure and the tendency to engage in high-risk behaviors. Emphasizing the impact of peer pressure on decision-making can help adolescents make safer choices. Choices A, C, and D are incorrect because adolescents actually have an increased risk of injury, increased responsibility does not always reduce risks, and many adolescents are at risk of engaging in substance abuse.

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