Nursing Elites

1. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

• A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
• B. Advance the stronger leg and the cane together to support the weaker leg
• C. Remove the rubber tip when using the cane
• D. Hold the cane on the right side to provide support for the weaker leg

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.

2. What is the priority action when a patient is experiencing an allergic reaction to a medication?

• A. Monitor the patient's blood pressure every 15 minutes.
• B. Discontinue the medication and notify the healthcare provider.
• C. Administer an antihistamine to reduce symptoms.
• D. Monitor the patient's urine output closely.

Correct answer: B

Rationale: The correct answer is to discontinue the medication and notify the healthcare provider when a patient is experiencing an allergic reaction to a medication. This action is crucial to prevent further harm to the patient. Monitoring blood pressure (choice A) or urine output (choice D) may be important but is not the priority when managing an allergic reaction. Administering an antihistamine (choice C) should only be done after discontinuing the medication and consulting with the healthcare provider.

3. A nurse is assigned to care for four clients. Which client should the nurse assess first?

• A. A client with chest pain and shortness of breath
• B. A client with a fever of 100°F
• C. A client scheduled for surgery
• D. A client with stable vital signs

Correct answer: A

Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.

4. A newly licensed nurse tells a charge nurse that he is unsure about accepting telephone medication prescriptions. Which of the following providers should the charge nurse identify as having the legal ability to give telephone medication prescriptions?

• A. Anesthesiologists
• B. Physician assistants
• C. Hospital pharmacists
• D. Nurse practitioners

Correct answer: A

Rationale: The correct answer is A: Anesthesiologists. Anesthesiologists are licensed providers who have the legal authority to give telephone medication prescriptions. Physician assistants (choice B), hospital pharmacists (choice C), and nurse practitioners (choice D) do not typically have the legal ability to provide medication prescriptions over the phone. In this scenario, the charge nurse should inform the newly licensed nurse that anesthesiologists are one of the providers who can legally give telephone medication prescriptions.

5. The nurse is evaluating the effectiveness of guided imagery for pain management in a patient with second- and third-degree burns requiring extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?

• A. The patient's need for analgesic medication decreases during the dressing changes.
• B. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
• C. The patient asks for pain medication during the dressing changes only once throughout the procedure.
• D. The patient's facial expressions remain stoic during the procedure.

Correct answer: A

Rationale: The correct answer is A. A reduction in the need for analgesic medication indicates that guided imagery is effective in managing the patient's pain. Choices B, C, and D do not directly measure the effectiveness of guided imagery. A patient rating pain as 6 on a scale of 0 to 10, asking for pain medication once, or having stoic facial expressions may not necessarily reflect the impact of guided imagery on pain management.

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