Nursing Elites

1. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

2. Which statement by the nurse indicates culturally responsive care for a client following Islamic practices?

• A. “I will make sure the menu includes halal options.”
• B. “I will ask the client if they want to schedule prayer times during the day.”
• C. “I will avoid discussing care when the client’s family is around.”
• D. “I will make sure daily communion is available for this client.”

Correct answer: B

Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.

3. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

• A. Impaired balance
• B. Hemiplegia
• C. Muscle sprain
• D. Lower extremity paralysis

Correct answer: A

Rationale: When the cerebellum is damaged, it leads to impaired balance. The cerebellum plays a crucial role in coordinating movements and maintaining balance. Therefore, assessing the patient's balance is essential in determining the extent of cerebellar damage. Options B, C, and D are incorrect because hemiplegia refers to paralysis of one side of the body, muscle sprain is a soft tissue injury, and lower extremity paralysis involves loss of function in the lower limbs. These conditions are not directly associated with damage to the cerebellum.

4. When reviewing EBP about the administration of O2 therapy, what is the recommended maximum flow rate for regulating O2 via nasal cannula?

• A. Regulate O2 via nasal cannula no more than 6L
• B. Regulate O2 via nasal cannula no more than 2L
• C. Regulate O2 via nasal cannula no more than 4L
• D. Regulate O2 via nasal cannula no more than 8L

Correct answer: A

Rationale: The correct answer is to regulate O2 via nasal cannula no more than 6L. This flow rate is generally recommended to ensure adequate oxygen delivery without causing discomfort or potential harm to the patient. Choices B, C, and D are incorrect as they suggest flow rates that are either too low (2L, 4L) or too high (8L). A flow rate of 2L might not provide sufficient oxygen, while 4L could be inadequate for some patients. On the other hand, a flow rate of 8L could be excessive and potentially harmful, leading to complications like oxygen toxicity. Therefore, the optimal recommendation is to regulate O2 via nasal cannula at a maximum of 6L to balance effectiveness and safety.

5. A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?

• A. Decreased white blood cell count
• B. Decreased respiratory rate
• C. Increased breath sounds
• D. Increased heart rate

Correct answer: C

Rationale: The correct answer is C: Increased breath sounds. When a client with pneumonia is receiving antibiotic therapy, increased breath sounds indicate that the lungs are clearing and the pneumonia is resolving. This improvement in breath sounds suggests that the antibiotics are effectively treating the infection. Choices A, B, and D are incorrect because a decreased white blood cell count, decreased respiratory rate, and increased heart rate are not specific indicators of the effectiveness of antibiotic therapy in treating pneumonia. While these parameters may change in response to treatment, they do not directly reflect the resolution of the pneumonia infection.

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