Nursing Elites

1. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

2. A client is being taught how to use a cane. Which instruction should the nurse include?

• A. Use the cane on the stronger side
• B. Use the cane on the weaker side
• C. Ensure the cane has a rubber tip
• D. Hold the cane 1-2 inches from the ground

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. This instruction is important because it provides better support and balance. Placing the cane on the stronger side helps to shift weight off the weaker or injured side, reducing the risk of falls and promoting stability. Choices B, C, and D are incorrect. Using the cane on the weaker side would not provide optimal support. While ensuring the cane has a rubber tip and holding it 1-2 inches from the ground are important, they are not as crucial as using the cane on the stronger side for proper support and balance.

3. A client with a new diagnosis of hypertension is receiving discharge teaching. What should the nurse emphasize regarding lifestyle changes?

• A. Limit sodium intake to 2 grams per day
• B. Increase fluid intake to 2 liters per day
• C. Avoid potassium-rich foods
• D. Avoid alcohol consumption

Correct answer: B

Rationale: The correct answer is to increase fluid intake to 2 liters per day. Adequate fluid intake helps manage hypertension and prevent fluid retention. Limiting sodium intake, avoiding potassium-rich foods, and abstaining from alcohol are important aspects of managing hypertension; however, in this scenario, emphasizing the increase in fluid intake is crucial for the client's understanding and compliance.

4. A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?

• A. Decreased heart rate
• B. Nausea
• C. Fever
• D. Weight gain

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.

5. A client expresses anxiety about an upcoming surgery. What should the nurse do?

• A. Administer a sedative
• B. Ask the client to describe their feelings
• C. Call the surgeon to address the anxiety
• D. Provide information on post-op care

Correct answer: B

Rationale: When a client expresses anxiety, it is essential for the nurse to encourage the client to verbalize their feelings. This helps the client express concerns, fears, and uncertainties, enabling the nurse to provide appropriate emotional support. Administering a sedative (Choice A) should not be the initial response as it does not address the underlying emotional needs of the client. Calling the surgeon to address anxiety (Choice C) may not be within the nurse's scope of practice and may not directly address the client's emotional needs. Providing information on post-op care (Choice D) is important but not the priority when the client is experiencing anxiety preoperatively.

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