Nursing Elites

1. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?

• A. Assess for edema
• B. Evaluate electrolytes
• C. Restrict fluid intake
• D. Administer diuretics

Correct answer: B

Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.

2. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

• A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
• B. Advance the stronger leg and the cane together to support the weaker leg
• C. Remove the rubber tip when using the cane
• D. Hold the cane on the right side to provide support for the weaker leg

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.

3. How should a healthcare professional manage a patient with a chest tube?

• A. Ensuring the chest tube is secured properly and functioning
• B. Checking for air leaks and ensuring drainage is working
• C. Ensuring chest tube drainage is below chest level
• D. Ensuring proper documentation of chest tube output

Correct answer: D

Rationale: Proper documentation of chest tube output is crucial in the care of a patient with a chest tube. While ensuring the chest tube is secured and functioning, checking for air leaks, and maintaining drainage below chest level are important aspects of care, documentation of output is essential for monitoring the patient's condition, assessing the effectiveness of treatment, and ensuring appropriate interventions if needed.

4. A school nurse is developing a teaching plan about testicular cancer for a group of clients. Which of the following information should the nurse include in the teaching?

• A. Perform a testicular self-examination weekly.
• B. Do not palpate the epididymis when performing a testicular self-examination.
• C. Expect testicles to be uniform in consistency when performing a testicular self-examination.
• D. Perform a testicular self-examination after a cool shower.

Correct answer: C

Rationale: The correct answer is C because testicles should be uniform in consistency when performing a self-exam, and any lumps or abnormalities should be reported. Choice A is incorrect as testicular self-examinations should be performed monthly, not weekly. Choice B is incorrect because the epididymis should be included in the examination. Choice D is incorrect because a warm shower helps relax the scrotum, making the exam easier to perform.

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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