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 answer is B: 'Ensure the cane has a rubber tip.' This instruction is essential for safety as the rubber tip prevents slipping, providing stability. Choice A is incorrect because the cane should be held on the stronger side to provide better support and balance. Choice C is incorrect as the cane should be used on the stronger, more dominant side. Choice D is also incorrect as a cane is not only used on stairs but also for general support and mobility.

2. A client at risk for pressure injuries is being cared for by a nurse. What intervention should the nurse implement?

• A. Keep the client in one position
• B. Use a special mattress for the client
• C. Turn the client every 4 hours
• D. Provide extra pillows for positioning

Correct answer: B

Rationale: The correct intervention for a client at risk for pressure injuries is to use a special mattress. Special mattresses help reduce the risk of pressure injuries by redistributing pressure on bony areas, thus preventing tissue damage. Keeping the client in one position (choice A) can actually increase the risk of pressure injuries due to prolonged pressure on specific areas. Turning the client every 4 hours (choice C) is important for preventing pressure injuries, but using a special mattress is a more effective intervention. Providing extra pillows for positioning (choice D) may offer some comfort but does not address the primary intervention of pressure redistribution that a special mattress provides.

3. A nurse is performing a focused assessment on a client with a history of chronic obstructive pulmonary disease (COPD). What finding should the nurse expect?

• A. Increased breath sounds
• B. Flushed skin
• C. Nasal flaring
• D. Decreased respiratory rate

Correct answer: B

Rationale: The correct answer is B: Flushed skin. Flushed skin is a common finding in clients with COPD who are experiencing dyspnea. Increased breath sounds (choice A) are not typically associated with COPD; they may indicate conditions like pneumonia. Nasal flaring (choice C) is more commonly seen in respiratory distress in pediatric patients. Decreased respiratory rate (choice D) is not a typical finding in COPD and could indicate respiratory depression.

4. A nurse is preparing to perform a routine abdominal assessment. Which action should the nurse take first?

• A. Percuss the abdomen
• B. Auscultate bowel sounds
• C. Inspect the abdomen
• D. Palpate the abdomen

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. Auscultation should be performed before palpation during an abdominal assessment to avoid altering bowel sounds. Inspecting the abdomen is important but should follow auscultation. Percussion and palpation should be done after auscultation and inspection to ensure an accurate assessment.

5. A nurse receives a report from assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Notify the provider
• B. Recheck the blood pressure
• C. Administer antihypertensive medication
• D. Document the blood pressure in the chart

Correct answer: B

Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.

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