Nursing Elites

1. A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include?

• A. “Keep a nightlight on in the bathroom”
• B. “Set room temperature to 68 degrees Fahrenheit”
• C. “Place throw rugs over electrical cords”
• D. “Use chairs without armrests”

Correct answer: A

Rationale: The correct answer is A: 'Keep a nightlight on in the bathroom.' This safety measure is crucial for older adults to prevent falls by enhancing visibility during nighttime bathroom visits. Choice B is incorrect because setting the room temperature to 68 degrees Fahrenheit may not be universally suitable for all older adults, as individual preferences vary. Choice C is incorrect as placing throw rugs over electrical cords poses a tripping hazard rather than enhancing safety. Choice D is incorrect as using chairs without armrests may not provide adequate support and stability for older adults, increasing the risk of falls.

2. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

• A. Abnormal breath sounds
• B. Cyanosis of the lips
• C. Increasing pulse rate
• D. Pulse oximeter reading of 92%

Correct answer: C

Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.

3. A client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?

• A. Administer diphenhydramine (Benadryl)
• B. Discontinue the antibiotic infusion
• C. Apply a cool compress to the rash
• D. Notify the healthcare provider

Correct answer: B

Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.

4. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

• A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
• B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
• C. The arms should be crossed over the chest or in the lap.
• D. The feet should be close together with toes pointed out.

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

5. The healthcare provider is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include...

• A. Notify the surgeon of the client’s concern
• B. Have the client sign a new surgical permit
• C. Add the client’s concern to the permit
• D. Inform the surgeon about the client’s concern

Correct answer: D

Rationale: In this scenario, the best course of action is to inform the surgeon about the client's concern. This action ensures that the surgeon is aware of the client's specific request or concern related to the procedure. By directly involving the surgeon, the client's preferences or needs can be addressed effectively, potentially avoiding any misunderstanding or dissatisfaction. Choice A has been corrected to 'Notify the surgeon of the client’s concern' as the operating room staff may not have the authority to make changes to the permit. Having the client sign a new surgical permit (Choice B) may not be necessary if the concern can be addressed by informing the surgeon, making Choice B less efficient. Adding the client’s concern to the permit (Choice C) without consulting the surgeon may not align with the standard procedure and could lead to confusion or legal issues if the surgeon is not aware of the client’s specific requests.

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