Nursing Elites

1. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be

• A. Wrap the stump with an elastic bandage to prevent swelling
• B. Keep the skin on the stump clean and dry
• C. Use alcohol to cleanse the stump daily
• D. Apply moisturizing lotion to the stump daily

Correct answer: B

Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.

2. The nurse is teaching a client with asthma to use a peak expiratory flow rate (PEFR) meter to manage asthma at home. The nurse knows the client understands the proper use of the meter when the client:

• A. Inhales as rapidly as possible when using the meter
• B. Records the highest of three readings
• C. Uses the meter after taking a bronchodilator
• D. Blows out forcefully into the meter after taking a deep breath

Correct answer: B

Rationale: The correct answer is B: 'Records the highest of three readings.' When using a peak expiratory flow rate (PEFR) meter, the client should record the highest of three readings to ensure an accurate measurement of their peak expiratory flow rate. Inhaling rapidly, using the meter after taking a bronchodilator, or blowing out forcefully into the meter after a deep breath are not correct techniques for using a PEFR meter and may lead to inaccurate results.

3. A client with hypocalcemia is receiving calcium gluconate. What assessment finding requires immediate intervention?

• A. Decreased deep tendon reflexes.
• B. Wheezing and stridor.
• C. Decreased bowel sounds.
• D. Positive Chvostek's sign.

Correct answer: B

Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.

4. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

• A. Instruct the client to inhale more deeply
• B. Remind the client to cough after using the spirometer
• C. Praise the client for correct usage
• D. Suggest increasing the frequency of spirometer use

Correct answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

5. A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). What laboratory result should the nurse monitor closely?

• A. White blood cell count of 15,000.
• B. Blood glucose level of 320 mg/dL.
• C. Sodium level of 145 mEq/L.
• D. Serum creatinine level of 1.0 mg/dL.

Correct answer: B

Rationale: A blood glucose level of 320 mg/dL indicates the need for insulin to manage diabetic ketoacidosis.

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