Nursing Elites

1. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

• A. I can place an oval corn pad over toes that have corns as long as I remove the pad weekly
• B. I should soak my feet in warm water daily to soften corns and calluses
• C. I can apply lotion to soften calluses as long as I don’t put lotion between my toes
• D. I should use an over the counter liquid medication to remove corns

Correct answer: C

Rationale: Applying lotion to the feet, avoiding between toes, is correct; over-the-counter treatments and soaking are not recommended.

2. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

• A. Encourage the patient to engage in self-care.
• B. Promote mobility in the patient.
• C. Encourage the patient to perform range of motion exercises.
• D. Assist the patient with comfort measures.

Correct answer: D

Rationale: The priority action for a patient with Impaired physical mobility related to pain is to assist the patient with comfort measures. By addressing pain through comfort measures, the patient will be more willing and able to move. Encouraging self-care (Choice A) may be important but addressing pain first is crucial in improving mobility. Promoting mobility (Choice B) and encouraging range of motion exercises (Choice C) are important but addressing the pain and providing comfort measures take precedence to improve the patient's physical mobility.

3. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?

• A. Avoid standing up too quickly.
• B. Increase fluid intake to stay hydrated.
• C. Eat more salt to help retain fluids.
• D. Wear compression stockings during the day.

Correct answer: A

Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.

4. When assessing bowel sounds, what action should a healthcare professional take?

• A. Listen to the bowel sounds before performing abdominal palpation
• B. Auscultate for 2 minutes to determine if bowel sounds are present
• C. Place the diaphragm of the stethoscope over each quadrant
• D. Ask the client to cough while auscultating

Correct answer: C

Rationale: When assessing bowel sounds, it is crucial to listen before performing any palpation as palpation can alter bowel sounds. The correct technique involves placing the diaphragm of the stethoscope over each quadrant of the abdomen to listen for bowel sounds. Auscultating for at least 5 minutes is recommended to accurately determine the presence or absence of bowel sounds. Asking the client to cough is not necessary for assessing bowel sounds and may not provide relevant information. Therefore, option C is the correct choice as it follows the appropriate procedure for assessing bowel sounds.

5. When reviewing a client’s fluid and electrolyte status, what should the nurse report to the provider?

• A. Potassium 5.4
• B. Sodium 140
• C. Calcium 8.6
• D. Magnesium 2.0

Correct answer: A

Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.

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