Nursing Elites

1. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?

• A. Move both crutches up first
• B. Step up with the unaffected leg first
• C. Lean forward on the crutches before stepping up
• D. Hold onto the handrail for support

Correct answer: B

Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.

2. A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?

• A. Heart rate 80/min
• B. Heart rate 90/min
• C. Respiratory rate 28/min
• D. Heart rate 146/min

Correct answer: D

Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.

3. A client has an NG tube that needs to be irrigated every 8 hours. Which solution should the nurse use to maintain fluid and electrolyte balance?

• A. Tap water
• B. Sterile water
• C. 0.9% sodium chloride
• D. 0.45% sodium chloride

Correct answer: C

Rationale: The correct solution to maintain fluid and electrolyte balance during NG tube irrigation is 0.9% sodium chloride. This solution is isotonic and helps prevent electrolyte imbalances. Using tap water or sterile water can lead to electrolyte disturbances due to their hypotonic nature, while 0.45% sodium chloride is hypotonic and may cause further imbalances in the client's electrolyte levels.

4. A client receiving chemotherapy has developed stomatitis. Which of the following interventions should the nurse implement?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct intervention for a client with stomatitis is to encourage them to eat soft foods. Soft foods help prevent further irritation of the mouth, making it easier for the client to eat and reducing discomfort. Providing lemon-glycerin swabs could be too harsh on the already irritated mucosa. Avoiding toothpaste is relevant for clients with stomatitis to prevent further irritation. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol can further irritate the mucosa.

5. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?

• A. Elevate the IV site and apply an ice pack
• B. Administer an anti-inflammatory medication
• C. Apply a cold compress to the IV site
• D. Discontinue the IV and notify the provider

Correct answer: D

Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.

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