Nursing Elites

1. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

2. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should prioritize seeing the client who has new onset dyspnea 24 hours after a total hip arthroplasty first. This sudden dyspnea could indicate a serious complication like a pulmonary embolism, which requires immediate assessment and intervention. Acute abdominal pain, a UTI with a low-grade fever, and pneumonia with an oxygen saturation of 96% are important concerns but are not as immediately life-threatening as potential pulmonary embolism indicated by sudden dyspnea postoperatively.

3. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following techniques should the nurse identify as indicating the correct method for eliciting the client's patellar reflex?

• A. Tap just below the knee
• B. Tap on the upper thigh
• C. Tap on the ankle
• D. Tap on the lower leg

Correct answer: A

Rationale: The correct technique for eliciting the client's patellar reflex is to tap just below the knee. This action stimulates the stretch receptors in the patellar tendon, leading to a reflex contraction of the quadriceps muscle and extension of the lower leg. Tapping on the upper thigh (Choice B) would not elicit the patellar reflex as it targets a different area. Similarly, tapping on the ankle (Choice C) or tapping on the lower leg (Choice D) would not produce the desired response associated with the patellar reflex, making them incorrect choices.

4. Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?

• A. Determine the reason why the client is refusing to use the incentive spirometer.
• B. Insist that the client use the incentive spirometer.
• C. Administer pain medication to help the client use the spirometer.
• D. Document the refusal in the client’s medical record.

Correct answer: A

Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.

5. A healthcare professional is caring for a group of clients. Which of the following measures should the professional take to prevent the spread of infection?

• A. Place a client with TB in a room with negative pressure airflow
• B. Use a disposable gown for contact precautions
• C. Place a client with MRSA in a private room
• D. Use a mask for clients with influenza

Correct answer: A

Rationale: Tuberculosis is an airborne infection, and placing a client with TB in a room with negative pressure airflow helps prevent the spread of the infection by containing the pathogens. This measure is crucial as it prevents the dissemination of TB droplet nuclei to other areas. Choice B, using a disposable gown for contact precautions, is important for preventing the transmission of infections spread by direct or indirect contact. Choice C, placing a client with MRSA in a private room, is essential to prevent the spread of MRSA through contact with others. Choice D, using a mask for clients with influenza, helps prevent the spread of influenza through respiratory droplets. However, negative pressure airflow is specifically required for airborne infections like TB, making it the most appropriate choice in this scenario.

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