Nursing Elites

1. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

• A. The client uses a walker to move from the bed to the chair.
• B. The client has a strong cough.
• C. The client can bear weight on both legs.
• D. The client has a normal respiratory rate.

Correct answer: C

Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.

2. A healthcare professional is assessing a client who has chronic pain. Which of the following findings should the healthcare professional expect?

• A. Hypotension
• B. Tachycardia
• C. Hyperthermia
• D. Depression

Correct answer: D

Rationale: The correct answer is D: Depression. Chronic pain is often associated with psychological effects like depression. Patients with chronic pain may experience feelings of hopelessness, helplessness, and despair, which are characteristic of depression. While chronic pain can lead to changes in vital signs like increased blood pressure and heart rate, hypotension, tachycardia, or hyperthermia are not typically expected findings solely due to chronic pain. Therefore, the healthcare professional should be alert to signs of depression in clients with chronic pain and address these psychological impacts appropriately.

3. During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?

• A. What is your marital status?
• B. How would you describe yourself?
• C. Are you employed?
• D. Do you have any children?

Correct answer: B

Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.

4. A client with a new diagnosis of COPD is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. You should increase your intake of high-calorie foods.
• B. You should decrease your intake of high-protein foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of high-fiber foods.

Correct answer: A

Rationale: The correct statement to include in the teaching for a client with a new diagnosis of COPD is that they should increase their intake of high-calorie foods. This is important to help maintain energy levels and manage weight. COPD can lead to increased energy expenditure due to the increased work of breathing, making it crucial to consume adequate calories for energy. High-calorie foods can help prevent weight loss and support overall nutritional status in COPD patients. Choice B is incorrect because high-protein foods are important for maintaining muscle mass in COPD patients. Choice C is incorrect as there is no need to avoid foods that contain lactose unless the client is lactose intolerant. Choice D is incorrect as increasing high-fiber foods may exacerbate symptoms like bloating and gas in COPD patients.

5. When educating a client on the proper use of a metered-dose inhaler (MDI), which of the following instructions should be included?

• A. Shake the inhaler before use.
• B. Inhale quickly and deeply.
• C. Use the inhaler as needed.
• D. Do not use a spacer with the inhaler.

Correct answer: A

Rationale: Shaking the inhaler before use is crucial to ensure proper mixing of the medication. This action helps distribute the medication evenly, allowing for consistent dosing with each use. It is a vital step in using a metered-dose inhaler correctly to optimize its effectiveness in managing respiratory conditions.

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