Nursing Elites

1. A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?

• A. Increase fiber intake
• B. Encourage the client to walk daily
• C. Use a stool softener as needed
• D. Use a laxative daily

Correct answer: A

Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice C) and using a laxative daily (choice D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.

2. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

3. A nurse is preparing to transfer a client from a bed to a chair. The client can bear partial weight and has upper body strength. What device should the nurse use?

• A. Mechanical lift
• B. Gait belt
• C. Slide board
• D. Stand-assist lift

Correct answer: D

Rationale: A stand-assist lift is the correct choice in this scenario. This device is suitable for clients who can bear partial weight and have upper body strength, as it allows them to actively participate in the transfer process. A mechanical lift is typically used for clients who are non-weight bearing or have limited mobility. A gait belt is used for providing support and stability during walking or transferring short distances. A slide board is used for transferring clients who are unable to bear weight and need assistance moving from one surface to another.

4. A client who has recently developed fever, confusion, and a decreased level of consciousness is being admitted by a nurse. What should the nurse do first after obtaining the client's history and assessment?

• A. Administer prescribed antibiotics
• B. Initiate seizure precautions
• C. Identify the client's needs
• D. Place the client in isolation

Correct answer: C

Rationale: The correct answer is to identify the client's needs first. This allows the nurse to prioritize interventions based on the assessment findings. Administering prescribed antibiotics (choice A) should be based on a medical prescription and the identified infection. Initiating seizure precautions (choice B) is important but not the immediate priority in this case. Placing the client in isolation (choice D) is premature as the nurse needs to first assess and address the client's condition.

5. A nurse is preparing to administer a medication to a client with a nasogastric (NG) tube. What action should the nurse take?

• A. Administer the medication with a straw
• B. Flush the NG tube with 30 mL of water before administration
• C. Crush all medications together
• D. Mix the medication with pudding

Correct answer: B

Rationale: The correct action for the nurse to take when administering medication to a client with a nasogastric (NG) tube is to flush the NG tube with 30 mL of water before administration. Flushing the tube with water helps ensure the patency of the tube and prevents clogging. Choice A is incorrect because administering the medication with a straw is not a recommended practice for NG tube administration. Choice C is incorrect because crushing all medications together may lead to potential drug interactions. Choice D is incorrect because mixing the medication with pudding is not a standard method for administering medication through an NG tube.

Similar Questions