Nursing Elites

1. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

• A. Encourage visitors during visiting hours.
• B. Keep the patient on fall precautions until discharge.
• C. Check on the patient every shift.
• D. Raise all four side rails.

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

2. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

• A. Assist the patient with comfort measures.
• B. Keep the patient as mobile as possible.
• C. Encourage the patient to perform ROM.
• D. Encourage the patient to do self-care.

Correct answer: A

Rationale: The correct answer is A: 'Assist the patient with comfort measures.' When a patient is experiencing impaired physical mobility due to pain, the priority action is to provide comfort measures to help manage the pain. By addressing the pain, the patient may then feel more comfortable moving and engaging in mobility exercises. Option B, 'Keep the patient as mobile as possible,' could exacerbate the pain and should not be the initial action. While encouraging range of motion (ROM) exercises (Option C) and self-care (Option D) are important aspects of care, addressing pain and comfort should take precedence in this scenario.

3. A client with a new prescription for levothyroxine is receiving teaching from a nurse. Which statement indicates understanding of the teaching?

• A. I should take this with food
• B. I will see immediate results
• C. I might not realize the full effect of the medication for several weeks
• D. I should stop if I feel better

Correct answer: C

Rationale: The correct answer is C: 'I might not realize the full effect of the medication for several weeks.' Levothyroxine is a medication that may take several weeks for the full effect to be evident. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect because immediate results are not expected with levothyroxine. Choice D is incorrect because stopping the medication without consulting a healthcare provider can be harmful, even if the client feels better.

4. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

• A. Mild redness at the incision site.
• B. Increased drainage from the surgical site.
• C. Fever of 101°F.
• D. Normal white blood cell count.

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

5. When caring for a client's tracheostomy at home, which instruction should the nurse include in the teaching?

• A. Clean with alcohol
• B. Cover the tracheostomy when outside
• C. Replace the tube weekly
• D. Use tap water to clean

Correct answer: B

Rationale: Covering the tracheostomy when outside is crucial as it helps prevent dust and other irritants from entering the airway, reducing the risk of complications. Cleaning with alcohol (choice A) can be too harsh for the skin around the tracheostomy site. While replacing the tube weekly (choice C) is important, it is typically done by healthcare providers. Using tap water to clean (choice D) is not recommended as it may introduce contaminants to the tracheostomy site.

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