Nursing Elites

1. Which is the correct method for teaching a client to use a cane when they have left-leg weakness?

• A. Use the cane on the weaker side of the body
• B. Advance the cane and the strong leg together
• C. Maintain two points of support on the floor at all times
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: C

Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.

2. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the nurse's immediate priority?

• A. Increase the oxygen flow rate
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Administer a bronchodilator

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the immediate priority for the nurse is to suction the tracheostomy. This action helps clear the airway of secretions and ensures that the client can breathe effectively. Increasing the oxygen flow rate may be necessary but addressing the airway obstruction is more critical. Notifying the physician immediately is important but may cause a delay in addressing the immediate need for airway clearance. Administering a bronchodilator may help with bronchospasm but should not take precedence over ensuring a clear airway in a client with respiratory distress.

3. A healthcare provider is caring for a client with a pressure ulcer and needs to review the client's medical history. Which of the following findings is expected?

• A. A Braden scale score of 20
• B. An albumin level of 3 g/dL
• C. A hemoglobin level of 13 g/dL
• D. A Norton scale score of 18

Correct answer: B

Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.

4. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

• A. List of prescribed medications
• B. Potential complications to report
• C. Family contact details
• D. Dietary restrictions

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

5. A nurse is reinforcing teaching about cane use for a client with left-leg weakness. What should the nurse instruct the client to do?

• A. Use the cane on the weak side
• B. Maintain two points of support on the ground at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: B

Rationale: The correct answer is B: Maintain two points of support on the ground at all times. When using a cane for left-leg weakness, the client should hold the cane in the right hand and advance the cane and the weak leg simultaneously. This technique provides the necessary support and stability. Option A is incorrect because the cane should be used on the side opposite the weakness to provide support. Option C is incorrect as advancing the cane too far with each step may cause the client to lose balance. Option D is incorrect because advancing the cane and the strong leg simultaneously does not provide the needed support for the weakened leg.

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