Nursing Elites

1. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

• A. Hand rolls
• B. A foot cradle
• C. A trapeze bar
• D. A trochanter roll

Correct answer: B

Rationale: A foot cradle is the correct choice for this situation. A foot cradle is used to reduce pressure on the tips of a patient's toes in individuals with poor lower extremity circulation. Hand rolls are not designed to address toe irritation specifically. A trapeze bar is used to assist patients with repositioning in bed, and a trochanter roll is used to support the hips and prevent external rotation of the legs, neither of which directly address toe irritation in this scenario.

2. A nurse at a provider’s office is discussing routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed?

• A. “So I don’t need the colon cancer screening for another 2 or 3 years.”
• B. “For now, I should continue to have a mammogram each year.”
• C. “Because the doctor just performed a Pap smear, I’ll return next year for another one.”
• D. “I had my glucose test last year, so I won’t need it again for 4 years.”

Correct answer: B

Rationale: The correct answer is B. Mammograms are recommended annually for women starting at age 40 or 45. This statement aligns with current guidelines for breast cancer screening in women without specific risk factors. Choice A is incorrect because colon cancer screenings are typically recommended at different intervals. Choice C is incorrect as Pap smears are usually done every 3-5 years based on age and risk factors. Choice D is incorrect because glucose testing is usually recommended more frequently, especially for individuals at risk for diabetes mellitus.

3. During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?

• A. Bruises on the arms in various stages of healing
• B. Recent weight gain
• C. Complaints of joint pain
• D. Frequent visits to different providers

Correct answer: A

Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.

4. A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?

• A. Empty the drainage bag at least every 8 hours
• B. Keep the drainage bag below the level of the bladder
• C. Use sterile technique to collect a specimen from the drainage system
• D. Secure the catheter to the lower abdomen with a securement device

Correct answer: B

Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).

5. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

• A. Encourage the patient to engage in self-care.
• B. Promote mobility in the patient.
• C. Encourage the patient to perform range of motion exercises.
• D. Assist the patient with comfort measures.

Correct answer: D

Rationale: The priority action for a patient with Impaired physical mobility related to pain is to assist the patient with comfort measures. By addressing pain through comfort measures, the patient will be more willing and able to move. Encouraging self-care (Choice A) may be important but addressing pain first is crucial in improving mobility. Promoting mobility (Choice B) and encouraging range of motion exercises (Choice C) are important but addressing the pain and providing comfort measures take precedence to improve the patient's physical mobility.

Similar Questions