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 discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

• A. To donate organs, a client must provide consent prior to death
• B. The transplant team will harvest the organs for donation from the donor client
• C. During admission, all clients over the age of 18 should be asked about their organ donor status
• D. The National Organ Transplant Act prohibits the sale and purchase of organs

Correct answer: C

Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.

3. A nurse is assessing the skin of an immobilized patient. What will the nurse do?

• A. Use a standardized tool such as the Braden Scale.
• B. Limit the amount of fluid intake.
• C. Have special times for inspection so as not to interrupt routine care.
• D. Assess the skin every 4 hours.

Correct answer: A

Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.

4. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

• A. Discontinue current medications
• B. Write new prescriptions
• C. Compare prescriptions with the client’s medications
• D. Ask the client to decide

Correct answer: C

Rationale: The correct action in the medication reconciliation process is to compare prescriptions with the client’s medications. This step ensures that there are no conflicting medications prescribed, reducing the risk of adverse drug interactions. Discontinuing current medications or writing new prescriptions without comparing them can lead to errors and potential harm. Asking the client to decide is not appropriate in this context as it is the nurse's responsibility to ensure medication safety based on professional judgment and knowledge.

5. A client complains of pain in the leg while in skeletal traction. What is the nurse's priority action?

• A. Increase the pain medication immediately
• B. Check for signs of infection
• C. Reposition the client's leg for comfort
• D. Notify the physician of the client's complaints

Correct answer: B

Rationale: The correct answer is B: Check for signs of infection. In skeletal traction, the priority action for the nurse when a client complains of pain in the leg is to first assess for signs of infection. Pain in skeletal traction can be a symptom of infection or other complications, so checking for signs of infection is crucial before considering other interventions. Increasing pain medication immediately (Choice A) may mask the symptoms of an underlying infection. Repositioning the client's leg for comfort (Choice C) may provide temporary relief but does not address the potential underlying issue. Notifying the physician of the client's complaints (Choice D) is important but assessing for infection should come first to ensure timely and appropriate intervention.

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