Nursing Elites

1. When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?

• A. Lock the wheels on both the bed and stretcher
• B. Adjust the bed to a low position
• C. Ask the client to assist in the transfer
• D. Use a transfer sheet without locking the wheels

Correct answer: A

Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.

2. A client who has recently started using a behind-the-ear hearing aid is being cared for by a nurse. Which of the following statements should the nurse identify as an indication that the client understands the use of assistive devices?

• A. “I will be sure to remove my hearing aid before taking a shower.”
• B. “I will keep my hearing aid in at all times, even when sleeping.”
• C. “I will clean my hearing aid with alcohol.”
• D. “I will turn off my hearing aid when not in use.”

Correct answer: A

Rationale: The correct answer is A. It is crucial for the client to remove the hearing aid before showering to prevent damage from moisture. Choice B is incorrect as wearing the hearing aid all the time, including during sleep, is not recommended and can cause discomfort or harm. Choice C is incorrect as alcohol can damage hearing aids; they should be cleaned with a solution recommended by the manufacturer to prevent harm. Choice D is incorrect because hearing aids should not be turned off when not in use; instead, they should be stored properly following the manufacturer's instructions to maintain functionality and battery life.

3. When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?

• A. Fungi
• B. Friction
• C. Nail polish
• D. Nail polish remover

Correct answer: A

Rationale: The nurse would most likely suspect fungi as the cause of thickened and separated toenails. Fungal infections can lead to changes in the nail structure, causing them to thicken and separate from the nail bed. Friction, nail polish, and nail polish remover are less likely to cause these specific nail changes. Friction typically leads to calluses or blisters, while nail polish and nail polish remover do not commonly result in thickened and separated toenails.

4. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

• A. Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae
• B. Use a mechanical lift
• C. Twist at the waist while holding the client
• D. Ask for assistance from another staff member

Correct answer: A

Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client’s hands on the nurse’s shoulders and the nurse’s hands under the client’s axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.

5. While documenting in a client’s medical record, which of the following entries should the nurse record?

• A. “Incision without redness or drainage”
• B. “Drank adequate amounts of fluid with meals”
• C. “Administered pain medication”
• D. “Oral temperature slightly elevated at 0800”

Correct answer: D

Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.

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