Nursing Elites

1. A nurse is reinforcing teaching about using a cane with a client who has left-leg weakness. What instruction should the nurse give?

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

Correct answer: C

Rationale: The correct instruction for a client with left-leg weakness using a cane is to maintain two points of support on the floor at all times. This technique provides stability and support while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice B is incorrect as advancing the cane and the strong leg together may not provide adequate support and balance. Choice D is incorrect as the distance to advance the cane with each step can vary depending on the individual's needs and abilities.

2. A nurse is teaching a client who has irritable bowel syndrome (IBS) about dietary modifications. Which of the following instructions should the nurse include?

• A. Increase fiber intake to 35 grams per day
• B. Avoid dairy products
• C. Eat small, frequent meals
• D. Avoid fruits and vegetables

Correct answer: C

Rationale: The correct answer is C: 'Eat small, frequent meals.' Eating small, frequent meals helps manage IBS symptoms by avoiding overloading the digestive system. Choice A is incorrect because increasing fiber intake may worsen symptoms in some individuals with IBS. Choice B is not a blanket recommendation for all IBS patients; some may tolerate dairy products well. Choice D is incorrect as fruits and vegetables are important sources of nutrients and should not be completely avoided unless specific triggers are identified.

3. What should be included in dietary teaching for a client with chronic kidney disease?

• A. Increase potassium-rich foods in the diet
• B. Limit potassium and phosphorus intake
• C. Increase intake of protein-rich foods
• D. Increase fluid intake to prevent dehydration

Correct answer: B

Rationale: The correct answer is to limit potassium and phosphorus intake for a client with chronic kidney disease. Excessive potassium and phosphorus can be harmful to individuals with compromised kidney function. Option A is incorrect because increasing potassium-rich foods can exacerbate hyperkalemia in individuals with kidney disease. Option C may not be ideal as excessive protein intake can put extra strain on the kidneys. Option D is not the priority; while adequate fluid intake is important, it is not the primary focus when teaching dietary considerations for chronic kidney disease.

4. A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?

• A. Hypertension.
• B. Tachycardia.
• C. Cold extremities.
• D. Diaphoresis.

Correct answer: C

Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.

5. A client expresses doubt about the benefits of surgery. Which response by the nurse is most appropriate?

• A. Ask the client to explain why they believe the surgery won't help.
• B. Comment on the client's doubt regarding the procedure's benefits.
• C. Assure the client that everything will be fine.
• D. Acknowledge the client's uncertainty about the surgery.

Correct answer: D

Rationale: Option D is the most appropriate response as it acknowledges the client's expressed uncertainty about the surgery. By acknowledging the client's feelings, the nurse validates their concerns and opens the door for further discussion. This approach can help build trust and rapport with the client. Option A focuses more on seeking justification for the client's belief rather than addressing the underlying emotion. Option B, while acknowledging doubt, does not directly address the client's feelings. Option C, although well-intentioned, dismisses the client's concerns without exploring them further.

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