Nursing Elites

1. The nurse is observing the way a patient walks. What aspect is the nurse assessing?

• A. Body alignment
• B. Gait
• C. Activity tolerance
• D. Range of motion

Correct answer: B

Rationale: The correct answer is B: Gait. Gait refers to the manner in which a person walks, including aspects such as stride length, step width, and walking speed. When a nurse observes a patient's gait, they are assessing their mobility and looking for any abnormalities or issues in their walking pattern. Choice A, body alignment, focuses more on the posture and position of the body rather than the actual walking pattern. Choice C, activity tolerance, relates to the ability to withstand physical activity without experiencing excessive fatigue. Choice D, range of motion, pertains to the extent of movement at a joint and is not directly related to observing the way a patient walks.

2. What are the signs of infection that should be monitored in a postoperative patient?

• A. Fever and chills
• B. All of the above
• C. Increased pain or tenderness
• D. Redness, swelling, and warmth at the surgical site

Correct answer: D

Rationale: The correct answer is D: 'Redness, swelling, and warmth at the surgical site.' These are specific signs of infection at the surgical site that a nurse should monitor for in a postoperative patient. While fever, chills, and increased pain can also indicate infection, the most direct signs are redness, swelling, and warmth at the surgical site. Therefore, 'D' is the best choice as it directly relates to the site of the surgery and is crucial to monitor for potential postoperative infections.

3. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?

• A. Bend at the waist when picking up objects.
• B. Avoid lying on the operative side.
• C. Avoid lifting more than 10 lb.
• D. Apply ice to the affected eye.

Correct answer: C

Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.

4. Which principle is most important for maintaining medical asepsis in a healthcare setting?

• A. Sterilize instruments only when visibly contaminated.
• B. Use sterile gloves for all patient interactions.
• C. Disinfect patient areas only at the end of the day.
• D. Clean hands thoroughly before and after patient contact.

Correct answer: D

Rationale: The correct answer is D: Clean hands thoroughly before and after patient contact. Hand hygiene is crucial for maintaining medical asepsis in a healthcare setting as it helps prevent the spread of infections between patients and healthcare workers. Choice A is incorrect because instruments should be sterilized regularly, not just when visibly contaminated. Choice B is incorrect as sterile gloves are not required for all patient interactions, only for specific procedures. Choice C is incorrect because patient areas should be disinfected regularly throughout the day, not just at the end of the day.

5. A patient is receiving enteral feedings through a nasogastric (NG) tube. What is the most appropriate nursing intervention?

• A. Flush the NG tube with water before and after each feeding.
• B. Check the placement of the NG tube before each feeding.
• C. Administer medications through the NG tube every 4 hours.
• D. Increase the feeding rate if the patient is tolerating well.

Correct answer: B

Rationale: Checking the placement of the NG tube before each feeding is crucial as it ensures the tube is correctly positioned, reducing the risk of complications such as aspiration or improper delivery of feedings. Flushing the NG tube with water before and after each feeding can disrupt the feeding schedule and is not a standard procedure. Administering medications through the NG tube every 4 hours may not be necessary for all patients and should be based on specific medication requirements. Increasing the feeding rate without proper assessment and monitoring can lead to feeding intolerance or complications, making it an inappropriate intervention.

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