Nursing Elites

1. A client is learning to use a cane. What instruction is essential for this client?

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

Correct answer: B

Rationale: The correct instruction for a client learning to use a cane is to maintain two points of support on the ground at all times. This ensures better stability and reduces the risk of falls. Choice A is incorrect because advancing the cane and the weaker leg simultaneously may lead to imbalance. Choice C is incorrect because the cane should be used on the stronger side to provide support. Choice D is incorrect because there is no specific measurement for advancing the cane with each step, and the focus should be on maintaining stability.

2. What are the key signs of hyperglycemia?

• A. Increased thirst and frequent urination
• B. Decreased appetite and low blood pressure
• C. Weight loss and nausea
• D. Increased sweating and confusion

Correct answer: A

Rationale: The correct answer is A: Increased thirst and frequent urination. These are classic signs of hyperglycemia, indicating elevated blood sugar levels. Choice B is incorrect as hyperglycemia usually presents with increased appetite rather than decreased appetite and low blood pressure. Choice C is incorrect as weight loss is more commonly associated with uncontrolled diabetes rather than hyperglycemia. Choice D is incorrect as increased sweating and confusion are not typical signs of hyperglycemia.

3. What is the role of the nurse in postoperative care for a patient with a hip replacement?

• A. Monitor for signs of infection and administer pain relief
• B. Ensure the patient follows a low-calcium diet
• C. Ensure the patient uses crutches to avoid pressure on the hip
• D. Monitor for signs of deep vein thrombosis

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of infection and administer pain relief. In postoperative care for a patient with a hip replacement, it is crucial for the nurse to monitor for signs of infection, such as increased pain, redness, swelling, or drainage from the surgical site. Administering pain relief is also important to ensure the patient's comfort and aid in their recovery. Choices B, C, and D are incorrect as they do not directly relate to the immediate postoperative care needs of a patient with a hip replacement. Ensuring a low-calcium diet, using crutches, or monitoring for deep vein thrombosis are not primary responsibilities in the immediate postoperative period for this type of surgery.

4. A client with hypertension is asking for lifestyle changes. What should the nurse recommend?

• A. Increase sodium intake to manage blood pressure
• B. Reduce caffeine and alcohol consumption
• C. Encourage the client to increase protein intake
• D. Increase intake of fruits and vegetables

Correct answer: B

Rationale: The correct answer is B: Reduce caffeine and alcohol consumption. This recommendation is crucial for managing hypertension as excessive caffeine and alcohol intake can elevate blood pressure. By reducing these stimulants, the client can help regulate their blood pressure levels. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is contraindicated in hypertension as it can lead to fluid retention and worsen blood pressure. Encouraging increased protein intake (Choice C) and increasing intake of fruits and vegetables (Choice D) are generally healthy dietary suggestions but not specifically targeted at managing hypertension.

5. A nurse is teaching a client with hypertension about using a blood pressure monitor. Which of the following instructions should the nurse include?

• A. Take your blood pressure after eating
• B. Sit quietly for 5 minutes before taking your blood pressure
• C. Use a blood pressure cuff that is too small
• D. Take your blood pressure while standing

Correct answer: B

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before taking their blood pressure. This is important because sitting quietly helps stabilize the heart rate, leading to a more accurate reading. Choice A is incorrect because taking blood pressure after eating can affect the readings. Choice C is wrong because using a blood pressure cuff that is too small can provide inaccurate readings. Choice D is also incorrect as blood pressure should be taken in a seated position for accurate results.

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