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 statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

• A. "I should put alcohol on my baby's cord 3-4 times a day."?
• B. "I should put the baby's diaper on so that it covers the cord."?
• C. "I should call the physician if the cord becomes dark."?
• D. "I should wash my hands before and after I take care of the cord."?

Correct answer: A

Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.

3. Distribution of a drug to various tissues depends on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug?

• A. skin
• B. adipose tissue
• C. skeletal muscle
• D. myocardium

Correct answer: D

Rationale: The tissue that would receive the highest amount of cardiac output and thus the highest amount of a drug is the myocardium. Highly perfused tissues include vital organs like the brain, heart, kidneys, adrenal glands, and liver. The myocardium, being part of the heart, receives a significant amount of cardiac output. Choices A (skin) and B (adipose tissue) are poorly perfused tissues and would not receive high amounts of cardiac output. Choice C (skeletal muscle) is also less perfused compared to the myocardium.

4. Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?

• A. Rectus femoris muscle
• B. Deltoid muscle
• C. Gluteal muscle
• D. Vastus lateralis muscle

Correct answer: D

Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.

5. How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?

• A. every 24 hours
• B. every 36 hours
• C. every 48 hours
• D. every 72 hours

Correct answer: A

Rationale: The correct answer is 'every 24 hours.' Changing the intravenous tubing on total parenteral nutrition solutions every 24 hours is crucial due to the high risk of bacterial growth. Bacterial contamination can lead to serious infections in patients receiving total parenteral nutrition. Choices B, C, and D are incorrect because waiting longer intervals between tubing changes increases the risk of bacterial contamination and infection, compromising patient safety. It is essential to maintain a strict 24-hour schedule to minimize the risk of complications associated with bacterial contamination.

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