Nursing Elites

1. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?

• A. Advise the UAP to resume positioning the client on schedule
• B. Notify the healthcare provider
• C. Document the UAP's actions
• D. Discuss the situation with the client’s family

Correct answer: A

Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.

2. To reduce the risk of being named in a malpractice lawsuit, which action is most important for the nurse to take?

• A. Adhere consistently to standards of care.
• B. Thoroughly document all client interactions.
• C. Build a good rapport with clients.
• D. Work closely with the healthcare team.

Correct answer: A

Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.

3. A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?

• A. Widening pulse pressure
• B. Sudden drop in heart rate
• C. A decrease in urine output
• D. Elevated blood pressure and widening pulse pressure

Correct answer: D

Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.

4. The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?

• A. Supine with the head elevated 30 degrees
• B. Left lateral with the right leg flexed
• C. Sims’ position with the right leg flexed
• D. Prone position with the head turned to the side

Correct answer: C

Rationale: Sims’ position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.

5. The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

• A. Stay with the client throughout the infusion.
• B. Keep emergency resuscitation equipment at the bedside.
• C. Obtain the client's allergy history.
• D. Ask the client about past allergic reactions to medications.

Correct answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

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