Nursing Elites

1. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

• A. I wish I didn't have to attach the electrodes to my skin
• B. I will need to shave the hair off the skin where I place the electrodes
• C. I hope I don't have to take as many pain pills
• D. It's unfortunate that I have to be in the hospital for this treatment

Correct answer: D

Rationale: TENS is a portable treatment that can be done at home, so the client should not expect to remain in the hospital for this treatment.

2. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?

• A. Uses a sterile bottled solution more than once within a 24-hour period.
• B. Uses surgical aseptic technique to suction an airway.
• C. Uses a clean technique for inserting a urinary catheter.
• D. Uses a cleaning stroke from the urinary meatus toward the rectum.

Correct answer: C

Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.

3. A client reports pain and swelling at the IV site. What should the nurse do first?

• A. Flush the IV line and continue the infusion.
• B. Stop the infusion and notify the healthcare provider.
• C. Increase the IV infusion rate to reduce discomfort.
• D. Apply a warm compress to the IV site and continue monitoring.

Correct answer: B

Rationale: The correct answer is B: Stop the infusion and notify the healthcare provider. Pain and swelling at an IV site can indicate infiltration or infection, which are serious complications. Stopping the infusion helps prevent further harm to the client, and notifying the healthcare provider promptly allows for appropriate assessment and intervention. Choice A is incorrect because flushing the IV line and continuing the infusion could exacerbate the issue. Choice C is incorrect as increasing the IV infusion rate is not the appropriate action for pain and swelling at the site. Choice D is incorrect because applying a warm compress may not address the underlying issue of infiltration or infection; it's crucial to stop the infusion and seek further guidance.

4. Which of the following foods is a good source of protein?

• A. Chicken
• B. Tofu
• C. Cheddar cheese
• D. Almonds

Correct answer: C

Rationale: Cheddar cheese is indeed a good source of protein, providing a significant amount per serving. While chicken and tofu are also high in protein, cheddar cheese can be a beneficial source, especially for individuals looking for non-meat options. Almonds, while nutritious, are not as high in protein compared to the other options listed.

5. The nurse is observing the way a patient walks. What aspect is the nurse assessing?

• A. Body alignment
• B. Gait
• C. Activity tolerance
• D. Range of motion

Correct answer: B

Rationale: The correct answer is B: Gait. Gait refers to the manner in which a person walks, including aspects such as stride length, step width, and walking speed. When a nurse observes a patient's gait, they are assessing their mobility and looking for any abnormalities or issues in their walking pattern. Choice A, body alignment, focuses more on the posture and position of the body rather than the actual walking pattern. Choice C, activity tolerance, relates to the ability to withstand physical activity without experiencing excessive fatigue. Choice D, range of motion, pertains to the extent of movement at a joint and is not directly related to observing the way a patient walks.

Similar Questions