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. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Census overdue

Correct answer: A

Rationale: The correct answer is A: Temperature. A high fever is a significant indicator of infection or other serious conditions, making it the priority finding. Elevated temperature indicates an immediate concern for infection, which can quickly escalate and lead to severe complications if not addressed promptly. While heart rate, abdominal tenderness, and census overdue are important aspects to consider in the client's care, addressing the fever takes precedence due to its potential severity and implications for the client's health.

3. A healthcare professional working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during their shift. Which of the following signatures may the healthcare professional legally witness?

• A. A 16-year-old client who is married
• B. A 27-year-old who has schizophrenia
• C. An adoptive parent who brings in their 8-year-old child
• D. A 17-year-old mother who brings in her toddler

Correct answer: A

Rationale: The correct answer is A. A 16-year-old who is married can legally sign an informed consent form. In this case, being married at 16 may indicate legal emancipation or the ability to consent to medical treatment. Choice B is incorrect because having schizophrenia doesn't automatically imply incapacity to provide informed consent. Choice C is incorrect as an adoptive parent does not have the legal authority to provide consent for medical treatment on behalf of a child without proper documentation. Choice D is incorrect as a 17-year-old mother would generally not have the legal capacity to give consent for her toddler, as parental consent is usually required for minors.

4. A healthcare professional is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?

• A. A patient who is afebrile
• B. A patient who is diaphoretic
• C. A patient with strong pedal pulses
• D. A patient with adequate skin turgor

Correct answer: B

Rationale: Excessive moisture on the skin, as seen in a diaphoretic patient, can lead to impaired skin integrity. Diaphoresis softens epidermal cells, promotes bacterial growth, and can cause skin maceration. Afebrile status, strong pedal pulses, and adequate skin turgor are not directly associated with an increased risk of impaired skin integrity. Afebrile indicates the absence of fever, not a risk to skin integrity. Strong pedal pulses suggest good circulation, which is beneficial for skin health. Adequate skin turgor is a sign of good hydration and skin elasticity, indicating a lower risk of impaired skin integrity.

5. A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?

• A. Evaluating healing of an incision
• B. Inserting an NG Tube
• C. Performing a simple dressing change
• D. Changing IV tubing

Correct answer: C

Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.

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