Nursing Elites

1. A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

• A. Assess mobility
• B. Monitor vital signs
• C. Provide pain relief
• D. Reinforce discharge teaching

Correct answer: A

Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.

2. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

3. A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?

• A. Use eye drops to soothe dryness
• B. Avoid rubbing the eye
• C. Sleep on the side of the affected eye
• D. Avoid lying on the affected side

Correct answer: D

Rationale: After cataract surgery, it is essential to avoid lying on the affected side to reduce pressure and promote healing. Sleeping on the side of the affected eye (Choice C) may increase pressure on the eye, leading to complications. While using eye drops to soothe dryness (Choice A) is generally recommended postoperatively, it is not as crucial as avoiding pressure on the eye. Rubbing the eye (Choice B) should be avoided to prevent irritation and potential damage, but it is not as critical as avoiding pressure on the affected eye.

4. Which of the following is an early indicator that a client with a tracheostomy may require suctioning?

• A. Decreased respiratory rate
• B. Irritability
• C. Bradycardia
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early indicator that suctioning is necessary for a client with a tracheostomy. Irritability can signal discomfort or difficulty breathing, which may be due to the need for suctioning to clear the airway. Decreased respiratory rate, bradycardia, and decreased oxygen saturation are not typically early indicators that suctioning is needed in a client with a tracheostomy. These symptoms may occur later if the airway is not cleared promptly.

5. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?

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

Correct answer: C

Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

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