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 caring for a client under airborne precautions notes that the client is scheduled for a nuclear scan. What is the appropriate action for the nurse to take?

• A. Planning to have the nuclear scan performed at the bedside
• B. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued
• C. Asking the technicians in the nuclear scan department to wear masks
• D. Placing a surgical mask on the client for transport and for contact with other individuals

Correct answer: D

Rationale: The correct action for the nurse is to place a surgical mask on the client for transport and for contact with other individuals when a patient under airborne precautions requires movement. This helps prevent the spread of infectious agents. Planning to have the nuclear scan at the bedside (Choice A) may not be feasible or appropriate. Calling the nuclear medicine department to delay the test (Choice B) may inconvenience the client and disrupt the scheduled procedure. Asking technicians in the nuclear scan department to wear masks (Choice C) does not provide adequate protection for others who may come into contact with the client outside the department.

3. A community nurse is instructing a group of newly licensed nurses about diseases that require airborne precautions. Which of the following diseases should the nurse include?

• A. Rubella
• B. Pertussis
• C. Influenza
• D. Varicella

Correct answer: D

Rationale: The correct answer is D, Varicella. Varicella (chickenpox) is a disease that requires airborne precautions to prevent its spread. Airborne precautions are necessary to prevent transmission of pathogens that remain infectious over long distances when suspended in the air. Rubella, pertussis, and influenza do not require airborne precautions. Rubella and pertussis require droplet precautions, while influenza requires droplet and contact precautions. Therefore, Varicella is the only disease in the list that necessitates airborne precautions.

4. A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

• A. Gelatin
• B. Broth
• C. Popsicle
• D. Yogurt

Correct answer: D

Rationale: The correct answer is D, Yogurt. Yogurt is not part of a clear liquid diet. A clear liquid diet includes transparent or translucent liquids such as gelatin, broth, and popsicles. Yogurt is a thicker consistency and contains solid particles, making it inappropriate for a clear liquid diet. Choices A, B, and C are suitable options for a client following a clear liquid diet.

5. Which of the following statements reflects the principles of sterile technique?

• A. Sterile objects that come in contact with unsterile objects are to be considered contaminated.
• B. Items in a sterile package must be used immediately once the package has been opened; otherwise, they are considered contaminated.
• C. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched.
• D. The edge of a sterile field and a border 1 inch (2.5 cm) inward is unsterile.

Correct answer: A

Rationale: The correct statement reflecting the principles of sterile technique is that sterile objects that come in contact with unsterile objects are considered contaminated. This principle is crucial in maintaining asepsis during medical procedures. Choice B is incorrect because items in a sterile package should only be used if they remain sterile; opening the package does not automatically contaminate the items. Choice C is incorrect as any part of a sterile field that hangs below the top of the table is considered unsterile. Choice D is incorrect as the edge of a sterile field and a border inward are typically considered unsterile to maintain the integrity of the sterile area.

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