Nursing Elites

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

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

Correct answer: A

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 ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.

2. A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?

• A. Heart rate 80/min
• B. Heart rate 90/min
• C. Respiratory rate 28/min
• D. Heart rate 146/min

Correct answer: D

Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.

3. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Elevated blood glucose.
• B. Decreased urine output.
• C. Dependent edema.
• D. Jaundice.

Correct answer: C

Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.

4. A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?

• A. Increased heart rate
• B. Persistent cough
• C. Constipation
• D. Sweating

Correct answer: B

Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.

5. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

• A. I will let the client know that I am available as the interpreter.
• B. I will receive a small fee for interpreting for this client.
• C. I am glad I am available today, but when I am not, you can use a family member.
• D. I will let the client know that an interpreter is unavailable during the night shift.

Correct answer: A

Rationale: Choice A is correct because the nurse should inform the client of their availability to interpret, ensuring that communication is clear and culturally appropriate. Choice B is incorrect as interpreters in healthcare settings usually do not receive fees for providing interpretation services. Choice C is incorrect because suggesting the use of a family member as an interpreter may not ensure accurate communication, as they may not be trained or impartial. Choice D is incorrect because stating that an interpreter is unavailable during the night shift does not address the current situation where the nurse has agreed to interpret for the client.

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