Nursing Elites

1. 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.

2. A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skill should the nurse expect?

• A. Jumps with both feet
• B. Runs with coordination
• C. Walks without assistance
• D. Kicks a ball forward

Correct answer: C

Rationale: At 15 months, a toddler should be able to walk without assistance. Walking without assistance is a major gross motor skill milestone at this age, indicating the child's physical development and coordination. Choices A, B, and D are developmentally inappropriate for a 15-month-old. Jumping with both feet, running with coordination, and kicking a ball forward typically develop later in a child's growth and are more advanced skills compared to walking independently.

3. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Administer antihypertensive medication
• B. Notify the healthcare provider
• C. Recheck the blood pressure
• D. Document the blood pressure in the chart

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

4. A nurse is providing discharge teaching to a client who has a prescription for home oxygen therapy. What should the nurse teach?

• A. Remove the oxygen tubing during meals
• B. Wear synthetic fabrics while using oxygen
• C. Use cotton fabrics when oxygen is in use
• D. Increase oxygen flow during physical activity

Correct answer: C

Rationale: The correct answer is C: 'Use cotton fabrics when oxygen is in use.' When a client is on oxygen therapy, it is essential to use cotton fabrics to reduce the risk of static electricity, which can ignite in the presence of oxygen. Choices A, B, and D are incorrect. Removing the oxygen tubing during meals is not necessary as long as proper precautions are taken to avoid tripping hazards. Synthetic fabrics should be avoided while using oxygen therapy to prevent static electricity buildup. Increasing oxygen flow during physical activity should be done according to the healthcare provider's instructions, not indiscriminately.

5. A nurse is providing discharge teaching for a client with a prescription for home oxygen therapy. Which instruction should the nurse include?

• A. Increase the oxygen flow rate when shortness of breath occurs
• B. Keep oxygen tubing away from heat sources
• C. Wear synthetic fabrics to prevent static
• D. Turn off the oxygen when not in use

Correct answer: B

Rationale: The correct instruction for a client with home oxygen therapy is to keep oxygen tubing away from heat sources to prevent fires and other hazards. Option A is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Option C is incorrect as synthetic fabrics can generate static electricity, which is a fire hazard. Option D is incorrect as oxygen should be left on as prescribed unless advised otherwise.

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