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. What are the risk factors for developing hypertension?

• A. High sodium diet and lack of physical activity
• B. Low potassium intake and excessive alcohol consumption
• C. Frequent exercise and low cholesterol diet
• D. Smoking and family history

Correct answer: A

Rationale: The correct answer is A: High sodium diet and lack of physical activity. These are established risk factors for developing hypertension as they contribute to elevated blood pressure. Choice B, low potassium intake and excessive alcohol consumption, may also impact blood pressure but are not as strongly associated with hypertension as high sodium intake and lack of physical activity. Choice C, frequent exercise and a low cholesterol diet, are actually beneficial for reducing the risk of hypertension. Choice D, smoking and family history, are more closely linked to other health conditions such as cardiovascular diseases, rather than being primary risk factors for hypertension.

3. A nurse is preparing to administer metoclopramide 10 mg IM. Available is metoclopramide 5 mg/mL. How many mL should the nurse administer?

• A. 1 mL
• B. 2 mL
• C. 3 mL
• D. 4 mL

Correct answer: B

Rationale: To administer 10 mg of metoclopramide, the nurse should administer 2 mL (10 mg / 5 mg per mL). Therefore, the correct answer is 2 mL. Choice A (1 mL) is incorrect because it would only deliver 5 mg of metoclopramide, which is half the required dose. Choice C (3 mL) and D (4 mL) are incorrect as they would provide more than the required dose of 10 mg.

4. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

• A. Ignore the behavior
• B. Reassign the AP
• C. Report the behavior to the manager
• D. Discuss this behavior with the AP while reinforcing expectations

Correct answer: D

Rationale: When a charge nurse observes repeated failure in a staff member's performance, it is essential to address the issue directly. Choice D is the correct answer as it involves discussing the behavior with the assistive personnel (AP) while reinforcing expectations. This approach helps in clarifying the expected standards, setting accountability, and providing an opportunity for improvement. Choices A, B, and C are incorrect. Ignoring the behavior (Choice A) does not address the problem and can lead to continued substandard care. Reassigning the AP (Choice B) may not solve the issue and can potentially transfer the problem to another area. Reporting the behavior to the manager (Choice C) without directly addressing it with the AP first may not promote a constructive approach to resolving the issue.

5. Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?

• A. Insert the suction catheter while the client is swallowing
• B. Apply intermittent suction when withdrawing the catheter
• C. Place the catheter in a clean, dry location for later use
• D. Hold the suction catheter with the non-dominant hand

Correct answer: B

Rationale: The correct technique when performing nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps reduce trauma to the mucosa by preventing prolonged suctioning. Choice A is incorrect because inserting the suction catheter while the client is swallowing may increase the risk of aspiration. Choice C is incorrect as placing the catheter in a clean, dry location for later use is not a safe practice as it can lead to contamination. Choice D is incorrect since it does not address the proper technique involved in nasotracheal suctioning.

Similar Questions