Nursing Elites

1. 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.

2. A client with left-leg weakness is learning to use a cane. Which teaching point is most appropriate?

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

Correct answer: B

Rationale: The correct teaching point is to maintain two points of support on the ground at all times when using a cane. This ensures stability and helps distribute weight evenly. Choice A is incorrect because the cane should be used on the stronger side of the body to provide support to the weaker leg. Choice C is incorrect as advancing the cane too far with each step can lead to imbalance. Choice D is incorrect as advancing the cane and the strong leg simultaneously may not provide adequate support for the weaker leg.

3. A client with multiple fractures following a motor-vehicle crash is struggling with opening a milk carton. Which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I can't brush my teeth properly
• B. I am so frustrated I can't open my milk carton
• C. I can't hold a pencil
• D. I can't write anymore

Correct answer: B

Rationale: The correct answer is B. Struggling to open a milk carton indicates difficulty with fine motor skills and activities of daily living. This statement suggests a need for assistance from an occupational therapist to improve hand strength, coordination, and independence in performing essential tasks. Choices A, C, and D do not directly relate to the need for occupational therapy services in this context. In contrast, the inability to open a milk carton highlights specific challenges that occupational therapy can address effectively.

4. What is the process for taking a telephone order from a provider?

• A. Patient name, drug, dose, route, frequency
• B. Read back for accuracy
• C. Have a witness listen to the order
• D. Write down the order and follow up

Correct answer: B

Rationale: The correct process for taking a telephone order from a provider involves reading back the information for accuracy. This step ensures that the order is correctly understood and reduces the risk of errors. While listing patient information (Choice A) is essential, it does not encompass the complete process of verifying the order. Having a witness listen to the order (Choice C) may not always be practical or necessary, as direct verification is more efficient. Writing down the order and following up (Choice D) is not as crucial as the immediate read-back process, which allows for real-time clarification and confirmation.

5. What is the most important nursing action when administering IV potassium?

• A. Monitor for decreased urine output
• B. Administer via IV push
• C. Administer slowly and dilute in IV fluids
• D. Ensure the client drinks 500 mL of water before administration

Correct answer: C

Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.

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