Nursing Elites

1. Which is the correct method for teaching a client to use a cane when they have left-leg weakness?

• A. Use the cane on the weaker side of the body
• B. Advance the cane and the strong leg together
• C. Maintain two points of support on the floor at all times
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: C

Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.

2. What is the primary intervention for a patient with a pneumothorax?

• A. Insert a chest tube
• B. Administer oxygen
• C. Monitor respiratory rate
• D. Administer analgesics

Correct answer: A

Rationale: The correct answer is to insert a chest tube. This intervention is considered the definitive treatment for a pneumothorax as it helps remove air or fluid from the pleural space, re-expanding the lung. Administering oxygen (Choice B) can be supportive but is not the primary intervention to treat a pneumothorax. Monitoring respiratory rate (Choice C) is important but does not address the underlying issue of air in the pleural space. Administering analgesics (Choice D) may help manage pain but does not treat the pneumothorax itself.

3. What advice should be given to a client experiencing constipation?

• A. Encourage the client to drink water frequently
• B. Increase dietary fiber to relieve constipation
• C. Administer a laxative to relieve discomfort
• D. Encourage the client to increase physical activity

Correct answer: B

Rationale: The correct advice to give to a client experiencing constipation is to increase dietary fiber. Dietary fiber helps relieve constipation by promoting regular bowel movements. Encouraging the client to drink water frequently (Choice A) is also important for overall bowel health, but increasing dietary fiber is more directly related to relieving constipation. Administering a laxative (Choice C) should not be the first-line recommendation and should only be considered if dietary and lifestyle changes do not work. Encouraging the client to increase physical activity (Choice D) can be beneficial for overall health but may not directly address the issue of constipation.

4. A client has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day?

• A. 20 mL
• B. 15 mL
• C. 25 mL
• D. 10 mL

Correct answer: A

Rationale: To administer a total of 300 mg daily (150 mg PO BID), the nurse should give 20 mL of the syrup. This is calculated by dividing the total daily dose (300 mg) by the concentration of the syrup (15 mg/mL), which equals 20 mL. Choice B (15 mL), C (25 mL), and D (10 mL) are incorrect because they do not accurately calculate the required volume of syrup needed to deliver the prescribed dose.

5. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

• A. Paradoxical excitement
• B. Headache
• C. Slowing of reflexes
• D. Fatigue

Correct answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

Similar Questions