Nursing Elites

1. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?

• A. A client who has a right femur fracture with no weight-bearing on the affected leg
• B. A client who has bilateral leg braces due to paralysis of the lower extremities
• C. A client who has bilateral knee replacements with partial weight-bearing on both legs
• D. A client who is able to bear full weight on both lower extremities

Correct answer: A

Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.

2. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

• A. Brachial pulse in the right arm
• B. Radial pulse in the right arm
• C. Brachial pulse in the left arm
• D. Radial pulse in the left arm

Correct answer: D

Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.

3. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?

• A. Redness and swelling are normal after surgery
• B. Any drainage from the incision site is not concerning
• C. Yellow drainage is normal
• D. I should monitor for increased redness or warmth

Correct answer: B

Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.

4. A nurse at a local health department is caring for a client who is newly diagnosed with listeriosis. Which of the following actions should the nurse plan to take?

• A. Provide the Centers for Disease Control (CDC) and Prevention with the client's information
• B. Inform the client that they are required to have health department staff directly observe their treatment
• C. Determine whether the condition is reportable under state requirements
• D. Find out whether the condition is endemic in the client's neighborhood

Correct answer: C

Rationale: The correct answer is C: 'Determine whether the condition is reportable under state requirements.' Listeriosis is a reportable disease, meaning healthcare providers are legally required to report cases to public health authorities. By checking the state requirements for reportable diseases, the nurse ensures compliance with public health regulations. Choice A is incorrect because providing the client's information to the CDC is not the immediate action needed. Choice B is incorrect as direct observation of treatment is not a standard procedure for listeriosis. Choice D is also incorrect as determining if the condition is endemic in the client's neighborhood is not the primary concern when managing a diagnosed case of listeriosis.

5. How can a healthcare provider prevent pressure ulcers in an immobile patient?

• A. Turn the patient every 4 hours.
• B. Provide the patient with a special mattress.
• C. Elevate the patient's legs to reduce pressure.
• D. Limit the patient's movement to reduce friction.

Correct answer: B

Rationale: Providing the immobile patient with a special mattress is an effective way to prevent pressure ulcers. Special mattresses help distribute pressure evenly and reduce the risk of developing pressure ulcers by relieving pressure on sensitive areas. Turning the patient every 4 hours (Choice A) is a standard practice to prevent pressure ulcers but may not be as effective as using a special mattress. Elevating the patient's legs (Choice C) can help with circulation but may not directly prevent pressure ulcers. Limiting the patient's movement (Choice D) can lead to other complications and is not a recommended method for preventing pressure ulcers.

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