Nursing Elites

1. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?

• A. Use the cane on the weak side of the body
• B. Advance the cane and the strong leg simultaneously
• C. Maintain two points of support on the floor
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: C

Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

2. A healthcare professional is reviewing the medical record of a client who has a prescription for levothyroxine. Which of the following findings should the healthcare professional identify as an indication of a need for dosage adjustment?

• A. Tremors
• B. Increased appetite
• C. Bradycardia
• D. Diarrhea

Correct answer: B

Rationale: Increased appetite may indicate that the client is experiencing symptoms of hyperthyroidism due to an excessive dose of levothyroxine. This finding suggests a need for a dosage adjustment to prevent potential complications. Tremors are more commonly associated with hyperthyroidism, not necessarily indicating a need for dosage adjustment. Bradycardia and diarrhea are not typical signs of an incorrect levothyroxine dosage and would not directly warrant a need for adjustment.

3. A client is being taught about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will take this medication on an empty stomach.
• B. If I forget to take a dose, I can take it later on the same day.
• C. I will skip my dose if I forget to take it.
• D. I can take an additional dose if I miss one.

Correct answer: B

Rationale: The correct answer is B because taking warfarin later on the same day if a dose is missed helps maintain therapeutic levels. Choice A is incorrect because warfarin should be taken with food to enhance absorption. Choice C is incorrect as skipping a dose can lead to fluctuations in warfarin levels. Choice D is incorrect as taking an additional dose can increase the risk of bleeding.

4. A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?

• A. Place the client in a prone position
• B. Place the client in a 30-degree lateral position
• C. Encourage the client to reposition every 4 hours
• D. Place the client in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: Place the client in a 30-degree lateral position. Positioning the client laterally reduces pressure on bony prominences, improving circulation and helping prevent pressure injuries. Placing the client in a prone position (choice A) increases pressure on the bony prominences, raising the risk of pressure injuries. Similarly, placing the client in a high Fowler's position (choice D) can also increase pressure on certain areas. While encouraging the client to reposition every 4 hours (choice C) is important, the specific lateral positioning is more beneficial in preventing pressure injuries.

5. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

• A. I will let the client know that I am available as the interpreter.
• B. I will receive a small fee for interpreting for this client.
• C. I am glad I am available today, but when I am not, you can use a family member.
• D. I will let the client know that an interpreter is unavailable during the night shift.

Correct answer: A

Rationale: Choice A is correct because the nurse should inform the client of their availability to interpret, ensuring that communication is clear and culturally appropriate. Choice B is incorrect as interpreters in healthcare settings usually do not receive fees for providing interpretation services. Choice C is incorrect because suggesting the use of a family member as an interpreter may not ensure accurate communication, as they may not be trained or impartial. Choice D is incorrect because stating that an interpreter is unavailable during the night shift does not address the current situation where the nurse has agreed to interpret for the client.

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