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 client is post-operative following abdominal surgery. Which of the following assessment findings would require immediate intervention?

• A. Absent bowel sounds
• B. Saturated abdominal dressing
• C. Pain level of 8/10
• D. Temperature of 100.4°F

Correct answer: B

Rationale: A saturated abdominal dressing is a critical finding that may indicate active bleeding or wound complications. Immediate intervention is necessary to prevent further complications, such as hypovolemic shock or infection. Absent bowel sounds, though abnormal, are a common post-operative finding and do not require immediate intervention. Pain level of 8/10 can be managed effectively with appropriate pain control measures and does not indicate an urgent issue. A temperature of 100.4°F is slightly elevated but may be a normal post-operative response to surgery and does not typically require immediate intervention unless accompanied by other concerning signs or symptoms.

3. What is the most important action for preventing infection in a client with a central venous catheter?

• A. Changing the catheter dressing every 72 hours.
• B. Flushing the catheter with heparin solution daily.
• C. Ensuring the catheter is clamped when not in use.
• D. Maintaining sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.

4. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?

• A. Record the coughing incident. No further action is required at this time.
• B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
• C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
• D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Correct answer: C

Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.

5. Why should a client with an ileal conduit be instructed to empty the collection device frequently?

• A. Force urine to back up into the kidneys.
• B. Suppress production of urine.
• C. Cause the device to pull away from the skin.
• D. Tear the ileal conduit

Correct answer: C

Rationale: A full urine collection bag can cause the device to pull away from the skin, leading to potential leakage and skin irritation. Choice A is incorrect because a full urine collection bag does not force urine to back up into the kidneys. Choice B is incorrect as a full collection bag does not suppress the production of urine. Choice D is incorrect as a full collection bag is unlikely to tear the ileal conduit.

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