Nursing Elites

1. When transferring a client with hemiparesis from a bed to a wheelchair, which safety measure should be implemented?

• A. Standing the client and walking them to the wheelchair
• B. Moving the wheelchair close to the client's bed and standing and pivoting the client on their unaffected extremity to the wheelchair
• C. Moving the wheelchair close to the client's bed and standing and pivoting the client on their affected extremity to the wheelchair
• D. Having the client stand and push their body to the wheelchair

Correct answer: C

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure is to move the wheelchair close to the client's bed and have the client stand and pivot on their unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls or injuries. Choice A is incorrect as it suggests walking the client, which may not be safe or feasible. Choice C is incorrect because pivoting on the affected extremity can increase the risk of injury. Choice D is incorrect as it does not consider the client's limitations and safety needs, as it involves pushing their body which may not be possible with hemiparesis.

2. Which of the following vaccines is not part of the regular schedule of immunizations for children?

• A. DTaP
• B. MMR
• C. Hib
• D. hepatitis A

Correct answer: D

Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.

3. Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?

• A. CVADs are more expensive than a peripheral IV.
• B. Weekly administration is possible.
• C. Chemotherapeutic agents can be caustic to smaller veins.
• D. The client or family can administer the drug at home.

Correct answer: C

Rationale: The correct advantage of using CVADs for chemotherapeutic agent administration is that chemotherapeutic agents can be caustic to smaller veins. Many chemotherapeutic drugs are vesicants, which can cause tissue damage even in low concentrations. Using a CVAD to administer these agents into a large vein is optimal as it reduces the risk of damage. Choice A is incorrect as CVADs are actually more expensive than a peripheral IV, making it a disadvantage. Choice B is incorrect because the frequency of administration depends on the specific drug being administered, not on the access device, so it does not represent a universal advantage. Choice D is incorrect because IV chemotherapeutic agents are typically not self-administered at home; they are usually given in a hospital, outpatient, or clinic setting, making it an invalid advantage of using CVADs.

4. During a health assessment, a nurse is assisting with gathering subjective data from a client and plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?

• A. Aunts, uncles, grandparents, and cousins
• B. Foster children and their parents
• C. Wife's children from a previous marriage
• D. Wife and wife's parents

Correct answer: B

Rationale: The correct answer is 'Aunts, uncles, grandparents, and cousins.' When gathering medical history from the client's extended family, it is essential to inquire about relatives beyond the nuclear family, such as aunts, uncles, grandparents, and cousins, as they share genetic and environmental influences. Choice C, 'Wife's children from a previous marriage,' pertains to stepchildren, not extended family members. Choice B, 'Foster children and their parents,' involves individuals who are not biologically related to the client's family. Choice D, 'Wife and wife's parents,' focuses solely on immediate family members and excludes the client's extended family members, which are crucial for a comprehensive health assessment.

5. The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?

• A. "I will hold my breath for 10 seconds after each puff."?
• B. "I will wait five minutes after taking this medication and then gargle water."?
• C. "I will wait at least one minute between each puff."?
• D. "I will take this medication daily even if I am not having symptoms."?

Correct answer: B

Rationale: The correct answer is, 'I will wait five minutes after taking this medication and then gargle water.' After using an inhaled glucocorticoid, it is essential to wait for 5 minutes and then gargle water to remove any residue from the mouth, which can reduce the risk of developing thrush, a fungal infection. Choice A is correct as holding the breath for 10 seconds after each puff helps the medication reach deep into the lungs. Choice C is also correct as waiting at least one minute between puffs ensures proper delivery of the medication. Choice D is incorrect because it is important to take the medication daily as prescribed to control asthma symptoms, even if the person is not experiencing any at that moment.

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