Nursing Elites

1. A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:

• A. standing the client and walking him or her to the wheelchair.
• B. moving the wheelchair close to the client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
• C. moving the wheelchair close to the client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
• D. having the client stand and push his body to the wheelchair.

Correct answer: B

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure involves moving the wheelchair close to the client's bed and having the client stand and pivot on his unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls and promoting a safer transfer. Choice A is incorrect because walking the client is unsafe and not recommended. Choice C is incorrect as pivoting the client on his affected extremity can lead to injury or falls due to weakness or lack of control. Choice D is incorrect as it puts the client at risk by requiring them to push their body, which may not be feasible or safe for someone with hemiparesis.

2. The client asks the nurse not to tell anyone outside of the care team about his positive HIV diagnosis. What response is most appropriate?

• A. "I have to inform all clients on the unit of your diagnosis as it is transmissible."?
• B. "I will not communicate your diagnosis to anyone without your permission."?
• C. "Because this is a communicable disease, it may need to be reported to the CDC."?
• D. "You should not be concerned with who I share your diagnosis with."?

Correct answer: C

Rationale: The most appropriate response is C: "Because this is a communicable disease, it may need to be reported to the CDC."? It is important to uphold patient confidentiality, but in the case of certain communicable diseases like HIV, there are legal requirements for mandatory reporting to public health authorities such as the CDC. Option A is incorrect because it violates patient confidentiality and does not consider legal obligations. Option B, while respecting the client's wishes, may not align with the legal requirement for reporting certain communicable diseases. Option D is inappropriate as it dismisses the client's concerns and rights regarding their health information.

3. While working the 11 p.m. to 7 a.m. shift at the long-term care unit, the nurse gathers the nursing staff to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait, suspecting alcohol intoxication. What is the most appropriate action for the nurse to take?

• A. Contact the nursing supervisor.
• B. Tell the staff member that she is not allowed to administer medications.
• C. Ask the staff member how much alcohol she has consumed.
• D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.

Correct answer: A

Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.

4. After undergoing gastric resection, the client is informed by the nurse that which of the following meals is most likely to cause rapid emptying of the stomach?

• A. a high-protein meal
• B. a high-fat meal
• C. a large meal regardless of nutrient content
• D. a high-carbohydrate meal

Correct answer: D

Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. On the other hand, high-fat and high-protein meals tend to delay gastric emptying. A large meal, regardless of nutrient content, can also delay gastric emptying due to the increased volume of food that needs to be processed.

5. Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared for first?

• A. A client who is scheduled for surgery at 1 p.m.
• B. A client in skeletal traction who has just received pain medication
• C. A client scheduled for physical therapy at 11 a.m.
• D. A client who is able to perform activities of daily living independently

Correct answer: A

Rationale: The priority should be given to the client who is scheduled for surgery at 1 p.m. Preparing a client for surgery involves various tasks such as physical and emotional preparation, following healthcare provider instructions, and potential last-minute changes in the surgical schedule. It is crucial to ensure the client is adequately prepared. Providing care to a client who just received pain medication can wait until the medication takes effect. Clients who are independent in performing daily activities and those scheduled for physical therapy later in the morning are not as high a priority as preparing a client for an upcoming surgery. Therefore, the client scheduled for surgery should be cared for first to ensure all necessary preparations are completed.

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