Nursing Elites

1. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

• A. Aligning a trochanter wedge between the client's legs.
• B. Placing a towel roll under the client's neck.
• C. Applying an orthotic to the client's foot.
• D. Positioning a pillow under the client's knees.

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

2. A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?

• A. Administer an antiemetic
• B. Irrigate the NG tube with sterile water
• C. Increase the suction setting
• D. Replace the NG tube

Correct answer: B

Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.

3. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?

• A. Use a separate washcloth for the child
• B. Apply cold compresses to the eyes
• C. Apply warm compresses to the eyes
• D. Keep the child home until symptoms have resolved

Correct answer: A

Rationale: The correct answer is to use a separate washcloth for the child. This is important to prevent the spread of infection when a child has conjunctivitis. Using the same washcloth can lead to cross-contamination and further spread of the condition. Applying cold or warm compresses may provide comfort but do not address the prevention of spreading the infection. Keeping the child home until symptoms have resolved may be necessary, but the primary focus should be on preventing the spread of the infection within the household.

4. What is the correct way to assess for pitting edema?

• A. Press over the bony area for 5 seconds and release
• B. Press over the skin for 10 seconds and check for discoloration
• C. Press the area and check for the presence of rash
• D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

5. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

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