Nursing Elites

1. What is the best teaching point for a client with left-leg weakness learning to use a cane?

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

Correct answer: B

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures better stability and support for the client while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice C is incorrect as advancing the cane too far with each step may compromise balance. Choice D is incorrect because advancing the cane and the strong leg together may not provide adequate support for the weaker leg.

2. A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?

• A. Use a phenol solution to clean the wound
• B. Place a warm compress over the wound
• C. Cleanse the wound from the center outwards
• D. Administer antibiotics prophylactically

Correct answer: C

Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.

3. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

4. A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will avoid feeding my baby for 12 hours
• B. I will apply diaper cream during each diaper change
• C. I will give my baby water between feedings
• D. I will apply warm compresses for my baby's comfort

Correct answer: B

Rationale: The correct answer is B. Applying diaper cream during each diaper change is important to prevent skin breakdown in infants with rotavirus. Rotavirus can cause diarrhea, which can lead to skin irritation. Avoiding feeding the baby for 12 hours (choice A) can lead to dehydration and is not appropriate. Giving water between feedings (choice C) can further contribute to dehydration. Applying warm compresses (choice D) may provide comfort but does not address the specific issue of preventing skin breakdown associated with rotavirus.

5. A nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

• A. Urine output of 20 mL/hr.
• B. Temperature of 36.5°C (97.7°F).
• C. Sanguineous drainage on the surgical dressing.
• D. WBC count of 9,000/mm3.

Correct answer: A

Rationale: The correct answer is A: Urine output of 20 mL/hr. A urine output less than 30 mL/hr can indicate decreased renal perfusion, potentially due to hypovolemia or other issues, and should be reported to the provider. B: A temperature of 36.5°C (97.7°F) falls within the normal range and does not require immediate reporting. C: Sanguineous drainage on the surgical dressing is expected in the early postoperative period and should be monitored but does not need immediate reporting unless excessive. D: A WBC count of 9,000/mm3 is within the normal range and does not indicate an immediate concern.

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