Nursing Elites

1. A healthcare professional is reviewing the medical record of a client with a hip fracture. Which finding is a risk factor for pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Use of a special mattress
• D. Urinary incontinence

Correct answer: C

Rationale: The correct answer is the use of a special mattress. Special mattresses are designed to reduce pressure on bony prominences, thereby helping to prevent pressure injuries. Frequent repositioning (Choice A) is actually a preventive measure for pressure injuries. Poor nutrition (Choice B) can contribute to delayed wound healing but is not a direct risk factor for pressure injuries. Urinary incontinence (Choice D) can increase the risk of skin breakdown but is not a direct risk factor for pressure injuries.

2. A healthcare professional is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the professional use?

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

Correct answer: C

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This lift provides support and assistance for clients to stand up and be safely transferred. A gait belt is used for providing support during walking or transferring short distances for clients who need minimal assistance with balance and strength. A mechanical lift is typically used for clients who are non-weight bearing or have limited weight-bearing capacity. A slide board is utilized for transferring clients who are unable to bear weight on their legs and need assistance in sliding from one surface to another.

3. A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?

• A. Use a heating pad for comfort
• B. Apply a barrier cream to the skin
• C. Reposition the client every 4 hours
• D. Change the client's position every 2 hours

Correct answer: C

Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.

4. A client has a new prescription for a cane. What instruction should the nurse include?

• A. Hold the cane on the weaker side
• B. Ensure the cane has a rubber tip
• C. Keep the cane on the dominant side
• D. Use the cane only on stairs

Correct answer: B

Rationale: The correct answer is B: 'Ensure the cane has a rubber tip.' This instruction is essential for safety as the rubber tip prevents slipping, providing stability. Choice A is incorrect because the cane should be held on the stronger side to provide better support and balance. Choice C is incorrect as the cane should be used on the stronger, more dominant side. Choice D is also incorrect as a cane is not only used on stairs but also for general support and mobility.

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

• A. Flush the NG tube with 60 mL of water
• B. Verify tube placement
• C. Crush the medications and dissolve them in water
• D. Administer all medications together

Correct answer: B

Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.

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