Nursing Elites

1. A client who has been on bed rest for several days is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care?

• A. Encourage the client to ambulate as tolerated.
• B. Apply antiembolism stockings as prescribed.
• C. Elevate the client's legs on a pillow.
• D. Perform passive range-of-motion exercises daily.

Correct answer: B

Rationale: Applying antiembolism stockings as prescribed (B) is an effective intervention to prevent deep vein thrombosis (DVT) in a client on bed rest. While encouraging ambulation (A), elevating the legs (C), and performing passive range-of-motion exercises (D) are also beneficial, compression stockings are particularly effective in reducing the risk of DVT by promoting venous return and reducing stasis in the lower extremities.

2. The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

• A. Performing ROM exercises during bathing.
• B. Changing the patient's position every two hours.
• C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
• D. Placing the patient in the prone position for one hour three times a day.

Correct answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

3. After insertion of the indwelling catheter, how should the nurse position the drainage container?

• A. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
• B. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
• C. At the head of the bed for easy and accurate measurement of urine.
• D. Beside the patient in their bed to avoid embarrassment.

Correct answer: B

Rationale: The correct position for the drainage container after inserting an indwelling catheter is to have it placed lower than the bladder. This positioning helps maintain a constant downward flow of urine from the bladder, preventing backflow and ensuring proper drainage. Choice A is incorrect because having the drainage tubing taut does not promote proper urine flow and may cause kinking. Choice C is incorrect as placing the container at the head of the bed does not affect drainage and is not necessary for accurate measurement. Choice D is incorrect as the positioning of the drainage container should prioritize proper drainage and care over potential embarrassment.

4. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

5. A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?

• A. Use distraction techniques during times of spiritual stress and crisis.
• B. Reassure the client that their faith will be regained with time and support.
• C. Consult with the staff chaplain and request that the chaplain visit with the client.
• D. Use reflective listening techniques when the client expresses spiritual doubts.

Correct answer: D

Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.

Similar Questions