Nursing Elites

1. The healthcare provider is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the healthcare provider use to help prevent injury secondary to this rotation?

• A. Hand rolls
• B. A trapeze bar
• C. A trochanter roll
• D. Hand-wrist splints

Correct answer: C

Rationale: A trochanter roll is the correct choice as it is used to prevent external rotation of the hips when the patient is in a supine position. Hand rolls (Choice A) are incorrect because they are used to prevent contractures of the fingers, wrist, and hand. A trapeze bar (Choice B) is not the correct option as it helps patients change positions in bed and aids with movement, not specifically for hip rotation. Hand-wrist splints (Choice D) are also incorrect as they are used to maintain the functional position of the wrist and hand, not to address hip rotation.

2. A client with a prescription for a clear liquid diet is receiving teaching about food choices from a nurse. Which of the following selections by the client indicates an understanding of the teaching?

• A. Gelatin
• B. Whole milk
• C. Cream soups
• D. Orange juice

Correct answer: A

Rationale: The correct answer is A: Gelatin. Gelatin is suitable for a clear liquid diet because it is transparent and free of solid particles. Clear liquid diets are designed to be easily digested and leave minimal residue in the gastrointestinal tract. Choices B, C, and D are not appropriate for a clear liquid diet. Whole milk, cream soups, and orange juice contain solid particles or pulp, which are not allowed on a clear liquid diet. Whole milk and cream soups are not clear liquids as they contain milk solids and vegetable particles respectively. Orange juice contains pulp, which is not part of a clear liquid diet. It is important for clients to follow dietary restrictions to achieve the intended therapeutic outcomes.

3. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?

• A. “Really, you look just fine to me. There’s no need to feel undesirable.”
• B. “I’m interested in finding out more about how your body feels to you.”
• C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
• D. “It’s still too soon to expect to feel normal. Give it a little more time.”

Correct answer: B

Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.

4. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain feel like burning or aching?
• C. Is the pain constant or intermittent?
• D. Does the pain feel like throbbing or stabbing?

Correct answer: A

Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.

5. A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?

• A. Montgomery straps
• B. Sterile gauze
• C. Adhesive tape
• D. Elastic bandages

Correct answer: A

Rationale: Montgomery straps are the correct choice in this scenario. They are specifically designed to secure dressings around drain sites, like Penrose drains, and are ideal for frequent dressing changes. Sterile gauze (Choice B) is commonly used for wound dressings but may not provide the best securement for drains. Adhesive tape (Choice C) can cause skin irritation and may not be suitable for securing drains. Elastic bandages (Choice D) are typically used for compression or support but are not appropriate for securing dressings around drain sites.

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