Nursing Elites

1. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

2. A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?

• A. Thread the IV catheter so that the hub rests at the insertion site
• B. Shave excess hair from around the insertion site
• C. Cleanse the site with hydrogen peroxide before IV catheter insertion
• D. Palpate the site carefully just before inserting the IV catheter

Correct answer: A

Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.

3. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

• A. Compare prescriptions with medications the client received during hospitalization.
• B. Only review the client’s current medications.
• C. Provide a list of medications without checking for interactions.
• D. Discuss the client’s medication history without verification.

Correct answer: A

Rationale: The correct answer is A: Compare prescriptions with medications the client received during hospitalization. This step is crucial in ensuring the accuracy of medication reconciliation. By comparing the current prescriptions with the medications administered during the hospital stay, the nurse can identify any discrepancies, omissions, or duplications in the medications. This comprehensive comparison helps prevent medication errors and ensures that the client's home medications align with the treatment received in the hospital. Choice B is incorrect because solely reviewing the client's current medications may overlook important changes or additions made during the hospitalization. Choice C is incorrect as providing a list of medications without checking for interactions can lead to potential adverse effects or drug interactions. Choice D is incorrect as discussing the client's medication history without verification may not provide an accurate representation of the medications the client actually received during the hospital stay.

4. A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

• A. The client is able to discuss the appropriate technique.
• B. The client is able to demonstrate the appropriate technique.
• C. The client states an understanding of the process.
• D. The client is able to write the steps on a piece of paper.

Correct answer: B

Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.

5. A client reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?

• A. Provide a late supper
• B. Offer a wet washcloth for the client to wash their face
• C. Perform range of motion exercises
• D. Prepare a hot cocoa or tea for the client

Correct answer: B

Rationale: Offering a wet washcloth for the client to wash their face is a soothing and calming activity that can help the client relax before bedtime, promoting better sleep. Providing a late supper can lead to indigestion and disrupt sleep. Performing range of motion exercises may increase alertness rather than promoting relaxation. Preparing a hot cocoa or tea containing caffeine close to bedtime can interfere with falling asleep.

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