Nursing Elites

1. A nurse is evaluating a client’s use of a cane. What is the correct use?

• A. Client holds the cane on the stronger side of the body.
• B. Client holds the cane on the weaker side of the body.
• C. Client holds the cane in front of the weaker side of the body.
• D. Client holds the cane in front of the stronger side of the body.

Correct answer: A

Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.

2. The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

• A. Administer antibiotic therapy for 10 days
• B. Teach the client isometric exercises for legs
• C. Assess movement and sensation of extremities
• D. Assist the client to stand up at the bedside within the first 24 hours

Correct answer: C

Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.

3. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

• A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
• B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
• C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
• D. Before changing assignments, determine which staff members have fitted particulate filter masks

Correct answer: D

Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.

4. The nurse is providing discharge teaching to a client who has been prescribed digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I should take my pulse before taking the medication.
• B. I will take my medication at the same time every day.
• C. I should avoid taking antacids at the same time as this medication.
• D. I should eat foods high in potassium while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Eating foods high in potassium can lead to hyperkalemia when taken with digoxin, indicating a need for further teaching. Choices A, B, and C are all correct statements that demonstrate understanding of digoxin therapy. Taking the pulse, maintaining a consistent dosing schedule, and avoiding antacids to prevent interactions with digoxin are all appropriate client responses.

5. When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?

• A. Capillary refill less than 3 seconds
• B. 1+ pitting edema in both feet
• C. Pale nail beds in both hands
• D. Thick skin on the soles of the feet

Correct answer: A

Rationale: The correct answer is A: Capillary refill less than 3 seconds. This finding is considered normal and indicates good peripheral perfusion. Pitting edema (choice B) and pale nail beds (choice C) are abnormal findings that may suggest underlying health issues. Thick skin on the soles of the feet (choice D) is not an expected normal finding during a skin assessment and could be indicative of a callus or other skin condition.

Similar Questions