Nursing Elites

1. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

• A. Educate the client about their current medical diagnosis.
• B. Refer the client to a meal delivery program.
• C. Identify environmental hazards in the home.
• D. Arrange transportation for the client to follow-up appointments.

Correct answer: C

Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.

2. A healthcare professional is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the healthcare professional recommend?

• A. Suction the airway every hour
• B. Keep the head of the bed at 30 degrees
• C. Change the ventilator tubing every day
• D. Administer a bronchodilator every 2 hours

Correct answer: B

Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.

3. What is the correct procedure for taking a telephone order from a provider?

• A. State patient name, drug, dose, route, frequency, and read back the order
• B. State the medication and ask for a witness to listen to the order
• C. Write down the order and verify with the provider within 12 hours
• D. Have the provider verify the order during the next in-person visit

Correct answer: A

Rationale: The correct procedure for taking a telephone order from a provider is to state the patient's name, drug, dose, route, frequency, and then read back the order to ensure accuracy. This process helps in preventing errors and ensures that all relevant information is correctly documented. Choice B is incorrect because having a witness listen to the order is not a standard practice and may not guarantee accuracy. Choice C is incorrect as verifying the order within 12 hours may lead to delays in patient care. Choice D is incorrect because waiting for the provider to verify the order during the next in-person visit could result in a significant delay in administering necessary medication.

4. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?

• A. Document the client's condition every 15 minutes.
• B. Attach the restraints to a non-moving part of the bed.
• C. Avoid requesting a PRN restraint prescription for clients who are aggressive.
• D. Remove the client's restraints based on the client's condition.

Correct answer: A

Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.

5. A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?

• A. Give a bedtime snack
• B. Encourage a short nap in the afternoon
• C. Encourage exercise right before bed
• D. Establish a regular exercise routine 2 hours or more before bedtime

Correct answer: D

Rationale: The correct answer is D. Establishing a regular exercise routine at least 2 hours before bedtime promotes better sleep in older adults. Giving a bedtime snack (choice A) may disrupt sleep due to digestion, encouraging a short nap in the afternoon (choice B) can interfere with nighttime sleep, and encouraging exercise right before bed (choice C) can increase alertness and make it harder to fall asleep.

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