Nursing Elites

1. When teaching a client about the correct use of a cane, what should the nurse include?

• A. Hold the cane on the weaker side
• B. Ensure the cane has a rubber tip
• C. Keep the cane on the dominant side
• D. Use the cane only on stairs

Correct answer: B

Rationale: The correct answer is B. When instructing a client on the use of a cane, it is essential to ensure that the cane has a rubber tip. This rubber tip helps prevent slipping, providing additional stability and safety. Option A, holding the cane on the weaker side, is incorrect as the cane should be held on the stronger side to provide better balance and support. Option C, keeping the cane on the dominant side, is also incorrect because the cane should be held on the stronger side. Option D, using the cane only on stairs, is not comprehensive as the cane can be used for support and balance while walking on level ground as well.

2. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

• A. Decreased hematocrit
• B. Increased heart rate
• C. Increased blood pressure
• D. Decreased respiratory rate

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

3. A healthcare professional is reviewing the lab results of a client who has been experiencing a fever for 3 days. What finding indicates fluid volume deficit (FVD)?

• A. Decreased hematocrit
• B. Increased white blood cell count
• C. Increased hematocrit
• D. Decreased white blood cell count

Correct answer: C

Rationale: Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. In FVD, there is a loss of fluid without a proportional loss of electrolytes, leading to hemoconcentration. Choices A, B, and D are incorrect. Decreased hematocrit and decreased white blood cell count are not typical findings in fluid volume deficit. An increased white blood cell count is more indicative of infection or inflammation rather than fluid volume deficit.

4. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Apply a moisture-retentive dressing
• C. Apply a heating pad to the site
• D. Keep the client on bedrest

Correct answer: B

Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.

5. A nurse is planning to teach a group of older adults about the prevention of osteoporosis. What information should the nurse include in the teaching?

• A. Increase intake of vitamin C
• B. Avoid weight-bearing exercises
• C. Perform weight-bearing exercises
• D. Limit sun exposure

Correct answer: C

Rationale: The correct answer is C: Perform weight-bearing exercises. Weight-bearing exercises help maintain bone density and reduce the risk of osteoporosis in older adults. Choice A, increasing intake of vitamin C, is not directly related to osteoporosis prevention. Choice B, avoiding weight-bearing exercises, is incorrect as weight-bearing exercises are beneficial for bone health. Choice D, limiting sun exposure, is not a key factor in osteoporosis prevention as moderate sun exposure is important for vitamin D synthesis which is essential for bone health.

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