Nursing Elites

1. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?

• A. A client who has a right femur fracture with no weight-bearing on the affected leg
• B. A client who has bilateral leg braces due to paralysis of the lower extremities
• C. A client who has bilateral knee replacements with partial weight-bearing on both legs
• D. A client who is able to bear full weight on both lower extremities

Correct answer: A

Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.

2. A nurse is preparing to administer a medication that requires a peak and trough level. What is the nurse's priority action?

• A. Administer the medication before the peak level is obtained.
• B. Withhold the medication until the trough level is obtained.
• C. Administer the medication based on the previous trough level.
• D. Ensure that the medication is administered within 2 hours of the peak level.

Correct answer: B

Rationale: The nurse's priority action should be to withhold the medication until the trough level is obtained. This is crucial to ensure accurate dosing based on the patient's levels. Administering the medication before the peak level is obtained (choice A) can lead to incorrect dosing. Administering the medication based on the previous trough level (choice C) may not reflect the current levels accurately. Ensuring that the medication is administered within 2 hours of the peak level (choice D) is not necessary for obtaining accurate peak and trough levels.

3. A nurse is teaching a client who has a new prescription for amoxicillin clavulanate to treat pharyngitis. Which statement indicates understanding?

• A. I will double my dose if I miss one
• B. I should take this medication on an empty stomach between meals
• C. I will take the medication until my sore throat goes away
• D. I will stop taking this medication if I develop itching

Correct answer: C

Rationale: The client should never double the dose if a dose is missed. This can lead to an overdose, which can cause serious adverse effects. Instead, the client should take the next dose as scheduled or consult the provider for guidance.

4. A patient has a DNR (do-not-resuscitate) order but their family insists on resuscitation if necessary. What should the nurse do?

• A. Follow the family's wishes to resuscitate.
• B. Explain that the nurse must follow the DNR order.
• C. Ask the provider for clarification on the DNR.
• D. Call the ethics committee to discuss the situation.

Correct answer: B

Rationale: The correct answer is B. The nurse must follow the legal DNR order, even if the family insists on resuscitation. Respecting the patient's wishes is crucial in providing ethical care. Choice A is incorrect because the nurse should prioritize the patient's documented wishes over the family's requests. Choice C may cause unnecessary delays in care as the DNR order is a legal document. Choice D is not the initial action to take in this situation; the nurse should first address the conflict between the family's wishes and the patient's DNR order.

5. What are the key considerations when administering opioid analgesics to a patient in pain?

• A. Monitoring for respiratory depression
• B. Administering opioid antagonist if needed
• C. Assessing respiratory rate and pain level before administration
• D. Monitoring the patient's level of consciousness

Correct answer: A

Rationale: The correct key consideration when administering opioid analgesics to a patient in pain is monitoring for respiratory depression. Opioids can lead to respiratory depression, making it crucial to carefully monitor the patient's breathing. Administering an opioid antagonist is not a key consideration during the administration of opioids; it is used to reverse opioid effects in cases of overdose, not as a routine practice. Assessing respiratory rate and pain level before administration is important but not the key consideration compared to monitoring for respiratory depression. Monitoring the patient's level of consciousness is also essential but not as critical as monitoring for respiratory depression when administering opioids.

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