Nursing Elites

1. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?

• A. Restrict the client's fluid intake for 4 hours following the procedure
• B. Apply cold compresses to the puncture site after the procedure
• C. Instruct the client to increase oral fluid intake after the procedure
• D. Keep the client in a prone position for 12 hours after the procedure

Correct answer: C

Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.

2. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?

• A. A client who has a right femur fracture with no weight-bearing on the affected leg
• B. A client who has bilateral leg braces due to paralysis of the lower extremities
• C. A client who has bilateral knee replacements with partial weight-bearing on both legs
• D. A client who is able to bear full weight on both lower extremities

Correct answer: A

Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.

3. How should a healthcare provider respond to a patient who is exhibiting signs of acute myocardial infarction (AMI)?

• A. Calling for emergency assistance immediately
• B. Administering nitroglycerin as prescribed
• C. Monitoring the patient's cardiac rhythm
• D. Administering oxygen and preparing for ECG

Correct answer: A

Rationale: When a patient is exhibiting signs of acute myocardial infarction (AMI), the priority action is to call for emergency assistance immediately. This ensures that the patient receives prompt and appropriate care, including interventions such as administering oxygen, nitroglycerin, and monitoring cardiac rhythm. Administering nitroglycerin should only be done if prescribed by a healthcare provider after assessment and confirmation of AMI. Monitoring the patient's cardiac rhythm is important but not the initial action needed in this critical situation. Administering oxygen and preparing for an ECG are important interventions but should follow the immediate step of calling for emergency assistance.

4. When is removal of the restraints by the nurse appropriate?

• A. When medication that has been administered has taken effect
• B. When no acts of aggression are observed in the hour following the release of two extremity restraints
• C. When the nurse explores with the client the reasons for the angry and aggressive behavior
• D. When the client apologizes and tells the nurse that it will never happen again

Correct answer: B

Rationale: The correct answer is B. The nurse can safely remove restraints once no aggressive behavior is observed after releasing two extremity restraints for an hour. Choice A is incorrect because the removal of restraints should be based on the client's behavior rather than just the effect of medication. Choice C is incorrect as exploring reasons for aggressive behavior should be done before or during the intervention, not as a condition for removing restraints. Choice D is incorrect since an apology from the client does not guarantee a change in behavior or indicate that it is safe to remove the restraints.

5. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?

• A. Positive Chvostek's sign
• B. Cool extremities
• C. Positive Phalen's sign
• D. Decreased radial pulse

Correct answer: C

Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.

Similar Questions