Nursing Elites

1. When palpating the client's neck for lymphadenopathy, where should the nurse position himself?

• A. At the client's back
• B. At the client's right side
• C. At the client's left side
• D. In front of a sitting client

Correct answer: D

Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.

2. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

• A. Encourage the client to drink liquids
• B. Perform active range of motion exercises
• C. Elevate the head of the bed to 45 degrees
• D. Provide a high-fiber diet to the client

Correct answer: B

Rationale: Performing active range of motion exercises is the priority intervention for a client on strict bed rest. These exercises help prevent complications such as thromboembolism and muscle atrophy by promoting circulation and maintaining muscle strength. Encouraging liquids, elevating the head of the bed, and providing a high-fiber diet are important interventions but not the priority when compared to preventing serious complications associated with immobility.

3. Which instructions should the nurse discuss with the client diagnosed with Raynaud’s phenomenon?

• A. Explain that exacerbations will not occur in the summer
• B. Use nicotine gum to help quit smoking
• C. Wear extra warm clothing during cold exposure
• D. Avoid prolonged exposure to direct sunlight

Correct answer: C

Rationale: The correct instruction for a client diagnosed with Raynaud’s phenomenon is to wear extra warm clothing during cold exposure. This is essential in preventing vasospasms triggered by cold temperatures, which can worsen symptoms of Raynaud's phenomenon. Choice A is incorrect because exacerbations can occur in any season. Choice B is irrelevant and not directly related to managing Raynaud's phenomenon. Choice D is also incorrect as sunlight exposure does not significantly impact Raynaud's phenomenon.

4. In patients with heart failure, which type of diet is most recommended?

• A. High-sodium
• B. Low-sodium
• C. High-fat
• D. Low-carbohydrate

Correct answer: B

Rationale: In patients with heart failure, a low-sodium diet is most recommended. This type of diet helps manage fluid retention by reducing the amount of sodium in the body. Excess sodium can lead to fluid accumulation, putting additional strain on the heart. High-sodium diets can exacerbate symptoms of heart failure by causing fluid retention and increasing blood pressure. High-fat and low-carbohydrate diets are not specifically recommended for heart failure patients and may not address the underlying issues related to fluid balance and heart function.

5. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: Correct care for a client in Buck’s traction includes turning the client to the unaffected side to prevent complications such as pressure ulcers. Additionally, asking the client to dorsiflex the foot on the affected leg helps prevent foot drop. Removing the foam boot three times per day to inspect the skin is unnecessary and could disrupt the traction, so it is not appropriate. Therefore, choices A and D are incorrect.

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