Nursing Elites

1. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

• A. The client should remove all scatter rugs from the floor and minimize clutter.
• B. The client should not limit her movement within the home unless advised by the physician.
• C. The client should have a raised toilet seat and grab bars available in the bathroom.
• D. The client should not wear a robe and socks while walking in the house.

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

2. While assessing a client’s skin, the nurse notes the presence of several large red-blue and purple areas on the client’s body that do not blanch when pressure is applied. The nurse documents this finding using which term?

• A. Psoriasis
• B. Anasarca
• C. Petechiae
• D. Ecchymosis

Correct answer: D

Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues, commonly known as a bruise. The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is characterized by scaly erythematous patches with silvery scales on top, usually found on specific areas like the scalp, elbows, knees, low back, and anogenital area. Anasarca is bilateral or generalized edema, indicating a central problem like congestive heart failure or kidney failure. Petechiae are tiny purple or red spots resulting from tiny hemorrhages within the dermal and subdermal areas. Therefore, in this case, the correct term to document the described finding is Ecchymosis.

3. What effect can medication bound to protein have?

• A. reduced drug availability
• B. limited distribution of the drug to receptor sites
• C. less availability to produce desired medicinal effects
• D. decreased metabolism of the drug by the liver

Correct answer: C

Rationale: Medication bound to protein leads to less availability to produce desired medicinal effects because only unbound drugs can interact with active receptor sites. If a drug is bound to protein, it cannot bind with a receptor site, reducing its effectiveness. Choice A is incorrect because binding to protein reduces drug availability. Choice B is incorrect because distribution to receptor sites is ineffective if the drug is bound to protein. Choice D is incorrect because metabolism does not occur until the drug is removed from the protein molecule by the liver, allowing the protein to return to circulation.

4. A client is scheduled to undergo a Papanicolaou (Pap) test in 1 week. Which statement does the nurse make to the client?

• A. 'If you are menstruating, use pads instead of a tampon.'
• B. 'Avoid intercourse for 24 hours before the scheduled examination.'
• C. 'Get a douching kit from the pharmacy and douche 2 hours before the examination.'
• D. 'If you are having a vaginal discharge, obtain a sample of the discharge for inspection.'

Correct answer: B

Rationale: The correct answer is to 'Avoid intercourse for 24 hours before the scheduled examination.' The Pap test is used to screen for cervical cancer. It is not performed during menstruation or if a heavy infectious discharge is present. Before the test, the client should not douche, have intercourse, or insert anything into the vagina within 24 hours. Instructing the client to use pads instead of a tampon when menstruating can interfere with the test results due to the presence of blood. Douching before the exam is discouraged as it can alter the cervical cells' appearance, affecting the test's accuracy. Obtaining a sample of vaginal discharge for inspection is not a standard pre-Pap test instruction and is unnecessary for the test.

5. During a voice test, how should the nurse provide words for the client to repeat?

• A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the client
• B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested
• C. Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested
• D. Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client

Correct answer: B

Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly. Choices A, C, and D are incorrect. Choice A is wrong as the voice should be whispered, not spoken in a soft tone. Choice C is inaccurate because a distance of 10 feet is too far for precise testing. Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.

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