Nursing Elites

1. What is the best teaching point for a client with left-leg weakness learning to use a cane?

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

Correct answer: B

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures better stability and support for the client while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice C is incorrect as advancing the cane too far with each step may compromise balance. Choice D is incorrect because advancing the cane and the strong leg together may not provide adequate support for the weaker leg.

2. A client is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

• A. Supine with head elevated
• B. Lateral recumbent
• C. Prone with arms at sides
• D. Sitting with back rounded

Correct answer: B

Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.

3. A client with a tracheostomy is experiencing increased secretions and labored breathing. What should the nurse do first?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Encourage the client to cough
• D. Notify the provider

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy first. When a client with a tracheostomy is experiencing increased secretions and labored breathing, suctioning the tracheostomy is the priority intervention to clear the airway and improve breathing. Administering a bronchodilator (Choice A) may help with breathing but should come after ensuring the airway is clear. Encouraging the client to cough (Choice C) may not be effective in clearing secretions from the tracheostomy. Notifying the provider (Choice D) can be done after ensuring immediate airway clearance.

4. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

• A. Your weight gain should be less than that for someone without diabetes.
• B. Your weight gain should be the same as that for someone without diabetes.
• C. You should not avoid gaining weight during pregnancy.
• D. You should gain more weight to support the pregnancy.

Correct answer: B

Rationale: During pregnancy, a client with type 2 diabetes mellitus should aim for a weight gain similar to someone without diabetes to ensure a healthy pregnancy. Choice A is incorrect because weight gain should not be less; it should be adequate for pregnancy. Choice C is inaccurate as gaining some weight is essential for a healthy pregnancy. Choice D is incorrect as gaining more weight than necessary can pose risks for both the client and the baby.

5. How should a healthcare professional manage a patient with a suspected stroke?

• A. Monitor for changes in neurological status and administer thrombolytics
• B. Monitor for speech difficulties and administer oxygen
• C. Provide IV fluids and monitor blood pressure
• D. Administer pain relief and monitor for respiratory failure

Correct answer: A

Rationale: Corrected Rationale: When managing a patient with a suspected stroke, it is crucial to monitor for changes in neurological status as this can provide important information about the patient's condition. Administering thrombolytics, if indicated, is a critical intervention in the acute phase of an ischemic stroke to help dissolve blood clots and restore blood flow to the brain. This choice is the correct answer because it addresses the immediate management needs of a patient with a suspected stroke. Choices B, C, and D are incorrect because while monitoring for speech difficulties, administering oxygen, providing IV fluids, monitoring blood pressure, administering pain relief, and monitoring for respiratory failure are important aspects of patient care, they are not the primary interventions for managing a suspected stroke.

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