Nursing Elites

1. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

• A. Lock beds and wheelchairs when not in use
• B. Administer a sedative at bedtime
• C. Provide information about home safety checks
• D. Teach balance and strengthening exercises

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

2. Which nursing action is essential when administering a blood transfusion?

• A. Ensure the blood is administered within 4 hours.
• B. Check the patient's vital signs every 30 minutes during the transfusion.
• C. Administer the transfusion at a slow rate for the first 15 minutes.
• D. Document the transfusion in the patient's medical record immediately after administration.

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.

3. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

• A. I wish I didn't have to attach the electrodes to my skin
• B. I will need to shave the hair off the skin where I place the electrodes
• C. I hope I don't have to take as many pain pills
• D. It's unfortunate that I have to be in the hospital for this treatment

Correct answer: D

Rationale: TENS is a portable treatment that can be done at home, so the client should not expect to remain in the hospital for this treatment.

4. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the professional expect?

• A. Albumin level of 3
• B. Hemoglobin of 12
• C. Normal skin moisture
• D. No signs of infection

Correct answer: A

Rationale: The correct answer is A: Albumin level of 3. A low albumin level indicates poor nutrition, which can contribute to the development of pressure ulcers. Choice B, Hemoglobin of 12, is within the normal range and is not directly associated with pressure ulcers. Choice C, Normal skin moisture, does not provide specific information related to pressure ulcers. Choice D, No signs of infection, while important, is not a direct finding associated with pressure ulcers.

5. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?

• A. Redness and swelling are normal after surgery
• B. Any drainage from the incision site is not concerning
• C. Yellow drainage is normal
• D. I should monitor for increased redness or warmth

Correct answer: B

Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.

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