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. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?

• A. Wear gloves when entering the patient's room.
• B. Place the patient in a private room.
• C. Use a dedicated blood pressure cuff for the patient.
• D. Dispose of all equipment in a biohazard bag.

Correct answer: A

Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.

3. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?

• A. Re-assess the patient.
• B. Complete an incident report.
• C. Notify the healthcare provider.
• D. Do nothing, as no harm has occurred.

Correct answer: C

Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.

4. What should be done to ensure safety during the transfer of a patient with limited mobility?

• A. Have the patient use a gait belt for support.
• B. Encourage the patient to hold onto a walker.
• C. Lock the wheels on the bed and wheelchair.
• D. Ask the patient to transfer independently.

Correct answer: C

Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.

5. A client with severe dyspnea is scheduled for multiple diagnostic tests. Which test should the nurse prioritize?

• A. Administer an echocardiogram first.
• B. Prioritize a chest x-ray for the client.
• C. Prepare the client for a CT scan.
• D. Order an MRI first.

Correct answer: B

Rationale: The correct answer is B: Prioritize a chest x-ray for the client. When a client presents with severe dyspnea, a chest x-ray should be prioritized as it helps in assessing the lungs and heart, which are crucial in cases of respiratory distress. Echocardiograms are more focused on assessing heart function and may not provide immediate information needed in cases of dyspnea. CT scans and MRIs are more detailed imaging studies that are not typically the first-line diagnostic tests for severe dyspnea.

Similar Questions