Nursing Elites

1. A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?

• A. Send a text to the client to confirm the location of the house
• B. Leave her purse and valuables on the seat in the car and lock the doors
• C. Ask the client to keep an extra set of keys in case the car is locked
• D. Keep the car windows rolled up when in an unfamiliar environment

Correct answer: D

Rationale: The correct answer is to keep the car windows rolled up when in an unfamiliar environment. This action helps uphold safety precautions for the home health nurse. When visiting a new client in an unfamiliar area, it is essential to ensure personal safety. Keeping the car windows rolled up can prevent potential intruders or unwanted individuals from gaining access to the nurse while in the vehicle. This precaution is important for personal safety and security. Choice A, sending a text to the client to confirm the location of the house, is not directly related to the nurse's safety during the visit. While communication with the client is important, it does not directly address the nurse's safety. Choice B, leaving her purse and valuables on the seat in the car, poses a security risk. It is not advisable to leave valuables visible in the car, as it may attract thieves and compromise the nurse's safety. Choice C, asking the client to keep an extra set of keys, is more related to accessibility and convenience rather than the nurse's safety. While having an extra set of keys may be helpful, it does not directly address safety precautions for the nurse.

2. Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?

• A. A physical therapist
• B. A speech therapist
• C. A social worker
• D. An occupational therapist

Correct answer: D

Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.

3. Which of the following constitutes the five rights of medication administration?

• A. Right client, right nurse, right time, right dose, right route
• B. Right client, right time, right dose, right route, right order
• C. Right client, right drug, right dose, right time, right route
• D. Right physician, right nurse, right client, right drug, right dose

Correct answer: C

Rationale: The five rights of medication administration are essential to ensure safe and effective drug delivery to clients. The correct answer includes ensuring the right client receives the right drug at the right dose, via the right route, and at the right time. These elements are crucial to prevent medication errors and ensure optimal therapeutic outcomes. Choice A is incorrect as it includes 'right nurse' which is not part of the five rights of medication administration. Choice B is incorrect as it includes 'right order' which is not part of the five rights. Choice C is incorrect as it includes 'right drug' and 'right route', but it lacks 'right client' and 'right time'. Choice D is incorrect as it includes 'right physician' which is not part of the five rights.

4. Madge is a 91-year-old nursing home resident with a history of dementia and atrial fibrillation who has been admitted to the hospital for treatment of pneumonia. As you are performing her bed bath, you note bruising around her breasts and genital area. What potential issue should be of major concern in Madge's situation?

• A. Idiopathic thrombocytopenic purpura (ITP)
• B. Embolic stroke
• C. Sexual abuse
• D. Nursing home-acquired pneumonia (NHAP)

Correct answer: C

Rationale: Bruising around the breasts and genitals should trigger concern for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on behalf of vulnerable populations, such as the elderly. According to the National Center on Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. In this scenario, given Madge's age, history of dementia, and the presence of unexplained bruising in sensitive areas, sexual abuse must be considered as a major concern. Idiopathic thrombocytopenic purpura (ITP) is a platelet disorder that presents with excessive bruising and bleeding, but it is less likely in this case as the bruising pattern is suggestive of a different cause. Embolic stroke is a neurological condition that typically presents with sudden onset neurological deficits and is not related to the observed bruising. Nursing home-acquired pneumonia (NHAP) is a common issue in elderly residents but would not manifest as bruising in specific areas like the breasts and genitals.

5. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

• A. The skin on the arm appears mottled
• B. The cold pack has been in place for 10 minutes
• C. The client complains of feeling nauseated
• D. The capillary refill in the area distal to the arm is 2 seconds

Correct answer: A

Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.

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