Nursing Elites

1. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

• A. List of prescribed medications
• B. Potential complications to report
• C. Family contact details
• D. Dietary restrictions

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

2. What is an important consideration in managing a patient with heart failure?

• A. Monitor daily weight
• B. Provide oxygen therapy
• C. Encourage low-sodium diet
• D. Monitor for signs of fluid overload

Correct answer: A

Rationale: The most important consideration in managing a patient with heart failure is to monitor daily weight. This allows healthcare providers to assess fluid retention, adjust medications based on weight changes, and detect early signs of worsening heart failure. While oxygen therapy may be necessary in acute situations, it is not a routine management strategy for stable heart failure patients. Encouraging a low-sodium diet is important to manage fluid retention, but daily weight monitoring is a more direct measure of fluid status. Monitoring for signs of fluid overload is essential, but monitoring daily weight is a proactive approach to detect fluid accumulation before overt symptoms appear.

3. What is the most effective way to prevent the spread of infection in a healthcare setting?

• A. Hand hygiene
• B. Wearing personal protective equipment
• C. Sterilizing equipment
• D. Isolating infected patients

Correct answer: A

Rationale: Hand hygiene is considered the most effective method to prevent the spread of infection in a healthcare setting. Proper hand hygiene, including washing hands with soap and water or using hand sanitizer, is crucial in reducing the transmission of pathogens from one person to another. While wearing personal protective equipment, sterilizing equipment, and isolating infected patients are also important infection control measures, they are not as universally effective as hand hygiene in preventing the spread of infections. Personal protective equipment can prevent contact with infectious materials, sterilizing equipment reduces the risk of contamination, and isolating infected patients helps prevent the spread of specific infections, but they are more targeted approaches compared to the broad and essential practice of hand hygiene.

4. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury for this client?

• A. Use a bed exit alarm system
• B. Raise all four side rails while the client is in bed
• C. Apply one soft wrist restraint
• D. Dim the lights in the client's room

Correct answer: A

Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.

5. A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

• A. Apply oxygen at 10 L/min via face mask
• B. Position the client on their side
• C. Call for a Cesarean delivery
• D. Administer oxytocin

Correct answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.

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