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 nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

• A. Urine output of 20 mL/hr.
• B. Temperature of 36.5°C (97.7°F).
• C. Sanguineous drainage on the surgical dressing.
• D. WBC count of 9,000/mm3.

Correct answer: A

Rationale: The correct answer is A: Urine output of 20 mL/hr. A urine output less than 30 mL/hr can indicate decreased renal perfusion, potentially due to hypovolemia or other issues, and should be reported to the provider. B: A temperature of 36.5°C (97.7°F) falls within the normal range and does not require immediate reporting. C: Sanguineous drainage on the surgical dressing is expected in the early postoperative period and should be monitored but does not need immediate reporting unless excessive. D: A WBC count of 9,000/mm3 is within the normal range and does not indicate an immediate concern.

3. When caring for a client with a wound infection, what should the nurse prioritize?

• A. Change the dressing daily
• B. Cleanse the wound with an antiseptic solution
• C. Apply a wet-to-dry dressing to the wound
• D. Perform a wound culture before administering antibiotics

Correct answer: D

Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.

4. A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?

• A. Drooping eyelids
• B. Unequal pupils
• C. Facial twitching
• D. Facial droop

Correct answer: A

Rationale: The correct answer is A: 'Drooping eyelids.' Ptosis, characterized by drooping of the eyelid, is a classic symptom seen in myasthenia gravis. This occurs due to muscle weakness, particularly in the muscles that control eyelid movement. Choice B, 'Unequal pupils,' is not associated with ptosis and may indicate other neurological issues. Choice C, 'Facial twitching,' is not a typical sign of ptosis but could be related to other conditions like nerve irritation. Choice D, 'Facial droop,' is more commonly seen in conditions affecting the facial nerve, like Bell's palsy, and is not a characteristic feature of myasthenia gravis.

5. A client with hypothyroidism may present with which of the following findings?

• A. Weight gain
• B. Hair loss
• C. Dry skin
• D. Diarrhea

Correct answer: C

Rationale: Dry skin is a common manifestation of hypothyroidism due to decreased thyroid hormone levels, leading to reduced sweating and oil production. Weight gain may occur due to a slowed metabolism, not diarrhea, as hypothyroidism is more commonly associated with constipation. Hair loss is typically associated with hyperthyroidism, not hypothyroidism.

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