Nursing Elites

1. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

• A. Implement a regular toileting schedule
• B. Encourage the client to wear athletic socks when ambulating
• C. Place all four bed rails in the upright position
• D. Require a family member to remain at the bedside

Correct answer: A

Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.

2. A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?

• A. White blood cell count of 8,000/mm³
• B. Potassium level of 4.0 mEq/L
• C. Creatinine level of 1.0 mg/dL
• D. Hemoglobin level of 12 g/dL

Correct answer: C

Rationale: An elevated creatinine level indicates impaired kidney function, which may affect the client's ability to undergo surgery. The other laboratory values (white blood cell count, potassium level, and hemoglobin level) are within normal ranges and do not directly impact the client's readiness for surgery.

3. A client with diabetes is being discharged. What is the most important teaching point?

• A. Monitor blood sugar levels once in the morning
• B. Administer insulin before meals as prescribed
• C. Take medication only when feeling unwell
• D. Monitor glucose levels weekly

Correct answer: B

Rationale: The most important teaching point for a client with diabetes being discharged is to administer insulin before meals as prescribed. This is crucial for managing blood sugar levels effectively and preventing complications. Monitoring blood sugar levels once in the morning (Choice A) is not sufficient for proper diabetes management, as levels can fluctuate throughout the day. Taking medication only when feeling unwell (Choice C) is not recommended as diabetes treatment is based on a regular schedule. Monitoring glucose levels weekly (Choice D) is not frequent enough to provide the necessary information for managing diabetes on a day-to-day basis.

4. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

• A. Apply counter-pressure for back pain
• B. Use deep breathing exercises
• C. Visualize the baby's head
• D. Use massage therapy

Correct answer: A

Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.

5. A client scheduled to begin chemotherapy is discussing alopecia with a nurse. Which of the following statements should the nurse make?

• A. Avoid washing your hair during treatment
• B. Your oncologist might prescribe a cold cap during treatment to reduce hair loss
• C. You'll need to apply sunscreen to the scalp
• D. You'll likely experience regrowth of hair within 6 months after treatment ends

Correct answer: B

Rationale: The correct answer is B. The nurse should inform the client that their oncologist might prescribe a cold cap during treatment to reduce chemotherapy-induced hair loss by cooling the scalp. Choice A is incorrect as washing the hair during treatment is generally recommended. Choice C is incorrect as sunscreen is not typically needed for the scalp in this context. Choice D is incorrect as regrowth of hair can vary among individuals and is not guaranteed within a specific timeframe.

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