Nursing Elites

1. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair
• B. The assistant inserted two (2) fingers under the proximal end of the stocking
• C. The assistant elevated the feet while lying down to put on the stockings
• D. The assistant made sure the toes were warm after putting the stockings on

Correct answer: A

Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.

2. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

• A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
• B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
• C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
• D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress

Correct answer: C

Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.

3. When assessing a client for an endocrine dysfunction, which question should the nurse ask?

• A. “Have you noticed any pain in your legs when walking?”
• B. “Have you had any unexplained weight loss?”
• C. “Have you noticed any change in your bowel movements?”
• D. “Have you experienced any joint pain or discomfort?”

Correct answer: B

Rationale: The correct answer is B: “Have you had any unexplained weight loss?” Unexplained weight loss can be a common symptom of various endocrine disorders, such as hyperthyroidism and diabetes. This weight loss is often despite an adequate or increased appetite. Choices A, C, and D are less likely to be directly associated with endocrine dysfunction. Pain in the legs when walking could be related to musculoskeletal issues, changes in bowel movements may suggest gastrointestinal concerns, and joint pain is more commonly linked to rheumatologic conditions rather than primary endocrine disorders.

4. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
• B. The nurse noted unilateral breast enlargement.
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.

5. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

• A. Encouraging family discussion of feelings
• B. Accepting the family’s experience of anger
• C. Facilitating the use of spiritual practices identified by the family
• D. All of the above

Correct answer: D

Rationale: When a nurse has developed a close relationship with a dying client's family, it is crucial to provide comprehensive support. Encouraging family discussion of feelings helps them express their emotions and concerns, fostering a sense of relief. Accepting the family's experience of anger without judgment validates their emotions and promotes trust. Facilitating the use of spiritual practices identified by the family acknowledges their beliefs and values, offering comfort and solace. Therefore, all of the above interventions are essential in providing holistic care and support during such a challenging time. Choices A, B, and C each play a vital role in addressing different aspects of the family's emotional and spiritual needs, making option D the correct answer.

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