Nursing Elites

1. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?

• A. Do not massage any reddened areas.
• B. Encourage passive range of motion exercises on extremities.
• C. Position the client laterally, supine, and prone in sequence.
• D. Gently lift the client when moving into a desired position.

Correct answer: D

Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.

2. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

• A. Administer regular insulin IV.
• B. Administer IV fluids at 250 ml/hr.
• C. Administer sodium bicarbonate IV push.
• D. Administer furosemide (Lasix) IV push.

Correct answer: A

Rationale: Administering regular insulin IV (A) is the initial intervention for a client with diabetic ketoacidosis (DKA) to rapidly reduce blood glucose levels. This is vital in reversing the ketosis and acidosis seen in DKA. Administering IV fluids (B) helps to correct dehydration and electrolyte imbalances. Administering sodium bicarbonate (C) and furosemide (D) may be necessary depending on the client's condition, but insulin administration takes precedence in the management of DKA.

3. The healthcare professional observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the healthcare professional's intervention?

• A. The cuff wraps around the girth of the leg.
• B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
• C. The client is placed in a prone position.
• D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

Correct answer: B

Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. Auscultating the popliteal pulse with the cuff on the lower leg is incorrect as it may lead to an inaccurate reading. Placing the client in a prone position and wrapping the cuff around the girth of the leg are acceptable practices. A systolic reading that is 20 mm Hg higher in the lower extremity compared to the arm is expected due to the difference in blood pressure between the upper and lower parts of the body.

4. When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

• A. On the left side of the bed facing the foot of the bed.
• B. On the right side of the bed facing the head of the bed.
• C. Perpendicular to the bed on the right side.
• D. Facing the bed on the left side of the bed.

Correct answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process. Choice B is incorrect because positioning the wheelchair on the right side facing the head of the bed would make it challenging for the client to transfer due to their right-sided hemiplegia. Choice C is incorrect as placing the wheelchair perpendicular to the bed on the right side may not provide the necessary space and angle for a safe transfer. Choice D is incorrect as facing the bed on the left side of the bed does not provide the optimal position for the client to transfer from the bed to the wheelchair effectively.

5. The client is being taught how to self-administer a subcutaneous injection. To ensure sterility of the procedure, which subject is most important for the instructor to include in the teaching plan?

• A. Hand washing before preparing the injection.
• B. Technique for drawing medication from a vial.
• C. Selection and rotation of injection sites.
• D. Proper disposal of injection equipment.

Correct answer: B

Rationale: To maintain the sterility of the procedure, it is crucial to teach the client the correct technique for drawing medication from a vial. This ensures that the medication remains sterile during preparation and administration. While hand washing, injection site selection, and equipment disposal are important aspects of injection safety, the key focus should be on maintaining the sterility of the medication itself to prevent infections and ensure the effectiveness of the treatment.

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