Nursing Elites

1. A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?

• A. When descending stairs, I will first shift my weight to my right (unaffected) leg.
• B. I will use crutches to support my weight on my left leg.
• C. When ascending stairs, I will lead with my left leg.
• D. I will keep my crutches under my arms for support.

Correct answer: A

Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.

2. The client has been diagnosed with deep vein thrombosis (DVT). Which symptom would be most concerning?

• A. Pain in the affected leg
• B. Redness and warmth in the affected leg
• C. Shortness of breath
• D. Swelling in the affected leg

Correct answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.

3. What intervention should be taken to minimize the risk for injury in a client with dementia?

• A. Use a bed exit alarm system.
• B. Place the client in restraints for safety.
• C. Ensure the client has frequent visitors to reduce isolation.
• D. Keep the client's room dark and quiet at night.

Correct answer: A

Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.

4. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

• A. Establish a toileting schedule to decrease episodes of incontinence
• B. Complete a functional assessment of the client's self-care abilities
• C. Apply a barrier ointment to intact areas that may be exposed to moisture
• D. Determine the size and depth of skin breakdown over the sacral area

Correct answer: D

Rationale: The first action the nurse should implement is to determine the size and depth of the skin breakdown over the sacral area. This initial assessment will provide crucial information on the extent of the damage and guide appropriate care interventions. Option A is not the priority in this scenario as the immediate concern is addressing the existing skin breakdown. Option B, completing a functional assessment, is important but should come after addressing the acute issue of skin breakdown. Option C, applying a barrier ointment, may be beneficial later but does not address the primary need of assessing the extent of the current skin damage.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?

• A. I will keep my oxygen tank upright at all times.
• B. I will not use petroleum jelly to keep my nose from drying out.
• C. I will not smoke or allow others to smoke around me.
• D. I will call my doctor if I have difficulty breathing.

Correct answer: B

Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy as it can increase the risk of fire. Using petroleum jelly near oxygen can lead to a fire hazard. Choices A, C, and D are correct statements that indicate proper understanding of oxygen therapy safety measures. Choice A emphasizes the importance of keeping the oxygen tank upright to prevent leaks, choice C highlights the necessity of avoiding smoking to prevent exacerbation of COPD, and choice D encourages seeking medical help promptly in case of breathing difficulties.

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