Nursing Elites

1. A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?

• A. Stand behind the client and prepare to catch them if they fall
• B. Assist the client to sit in the nearest chair or slide down along a wall
• C. Grasp the client under the arms and pull them upward
• D. Call for help from nearby staff

Correct answer: A

Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.

2. When assisting a client with shampooing his hair while he is still in bed, a nurse raises the bed to approximately the level of her waist. What is the rationale for this action?

• A. To prevent shampoo from getting into the client's eyes
• B. To allow excess water to run off the edge of the bed
• C. To decrease strain on the nurse's back
• D. To prevent the client's hair from developing tangles

Correct answer: C

Rationale: Raising the bed to the level of the nurse's waist while assisting a client with shampooing in bed is done to reduce strain on the nurse's back. This adjustment ensures that the nurse can work comfortably without excessive bending or stooping, thus preventing back injuries. Choices A, B, and D are incorrect. While preventing shampoo from getting into the client's eyes, allowing excess water to run off the bed, and preventing hair tangles are important considerations, the primary rationale for raising the bed is to prioritize the nurse's ergonomic safety and prevent musculoskeletal strain.

3. When caring for children with a different cultural perspective, what challenge may the nurse recognize?

• A. Children have spiritual needs that are influenced by their stages of development
• B. Children have spiritual needs that are direct reflections of what is occurring in their homes
• C. Religious beliefs rarely affect the parents' perceptions of the illness
• D. Parents are often the decision-makers, and they have no knowledge of their children's spiritual needs

Correct answer: A

Rationale: When caring for children with different cultural perspectives, nurses should acknowledge that children have spiritual needs that are influenced by their stages of development. This understanding is crucial as children, like adults, have varying spiritual needs based on their age and the religious environment within their family. Recognizing and addressing these spiritual needs is essential for providing holistic care. Choices B, C, and D are incorrect as they do not accurately reflect the influence of children's developmental stages on their spiritual needs and the importance of considering these needs in their care.

4. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?

• A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
• B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
• C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
• D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.

Correct answer: C

Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.

5. What is the primary purpose of emergency planning?

• A. Comply with the laws of the state.
• B. Comply with the laws of the U.S.
• C. Comply with both state and U.S. laws
• D. Maintain safety

Correct answer: D

Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.

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