Nursing Elites

1. A patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?

• A. Turn and reposition the patient every 2 hours.
• B. Apply a moisture barrier to the patient's skin.
• C. Massage the patient's skin to promote circulation.
• D. Apply a heating pad to the patient's skin to increase blood flow.

Correct answer: A

Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.

2. Which of the following is an example of professional negligence?

• A. Following facility guidelines at all times
• B. Using equipment in a knowledgeable manner
• C. Communicating effectively with clients
• D. Documenting client interactions accurately

Correct answer: A

Rationale: Professional negligence involves failing to meet the standard of care expected in a particular profession, which can lead to harm. In this case, not following facility guidelines can result in lapses in safety or quality of care, potentially causing harm to clients. Choices B, C, and D all represent essential aspects of professional conduct and do not directly relate to negligence.

3. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

• A. Hold the cane with your left hand
• B. Move the cane forward 18 inches with each step
• C. When walking, move your left foot forward first
• D. Keep your elbow straight when you hold the cane

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

4. What are the nursing interventions for a patient with acute kidney injury (AKI)?

• A. Preparing the patient for dialysis if necessary
• B. Providing dietary modifications to reduce potassium
• C. Monitoring urine output and electrolytes
• D. Administering fluids and monitoring blood pressure

Correct answer: A

Rationale: The correct nursing intervention for a patient with acute kidney injury (AKI) includes preparing the patient for dialysis if necessary. While choices B, C, and D are also important aspects of managing AKI, the critical intervention in severe cases is to prepare the patient for dialysis to support kidney function. Providing dietary modifications to reduce potassium, monitoring urine output and electrolytes, and administering fluids are essential components of the overall care plan for AKI patients, but in cases where the condition is severe or if conservative management fails, dialysis may be required to support the patient's kidney function and prevent further complications.

5. What intervention should the nurse implement for a patient receiving a blood transfusion?

• A. Administer antihistamines to prevent allergic reactions.
• B. Monitor the patient for signs of circulatory overload.
• C. Ensure the blood transfusion is completed within 4 hours.
• D. Check the patient's vital signs every 30 minutes during the transfusion.

Correct answer: B

Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.

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