Nursing Elites

1. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

• A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
• B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
• C. Assist the client to a standing position by gently lifting upward underneath the axillae.
• D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Correct answer: B

Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.

2. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

• A. Remind the child to clean his genital area.
• B. Defer perineal care due to the child's age.
• C. Retract the foreskin gently to cleanse the penis.
• D. Inquire about the reason for the child not being circumcised.

Correct answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

3. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

• A. Acknowledge that she is supporting the arm correctly.
• B. Encourage her to keep the joint uncovered to maintain warmth.
• C. Reinforce the need to grip directly under the joint for better support.
• D. Instruct her to grip directly over the joint for better motion.

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

4. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding is most consistent with this diagnosis?

• A. Dependent edema.
• B. Ascites.
• C. Nocturia.
• D. Orthopnea.

Correct answer: D

Rationale: Orthopnea (D) is most consistent with left-sided heart failure. It is characterized by difficulty breathing when lying flat and is relieved by sitting up or standing. Dependent edema (A), ascites (B), and nocturia (C) are more commonly associated with right-sided heart failure. Dependent edema refers to swelling due to fluid accumulation, ascites is the accumulation of fluid in the peritoneal cavity, and nocturia is the excessive need to urinate during the night, all of which are more indicative of right-sided heart failure.

5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low carbohydrate and high protein meals
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

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