Nursing Elites

1. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?

• A. "At least two (2) full meals a day are eaten."?
• B. "We go to a group discussion every week at our community center."?
• C. "We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?
• D. "The medication is not a problem to have taken three (3) times a day."?

Correct answer: C

Rationale: The correct answer is, '"We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?' Ensuring the safety of a client with Alzheimer's disease is crucial in home care. Installing safety features like bars in the bathroom and alarms on doors help prevent accidents and injuries. This contributes to creating a safe environment that promotes independence and autonomy for the client. Choices A, B, and D are incorrect because while they are important aspects of care, ensuring safety in the home environment takes precedence in caring for a client with Alzheimer's disease.

2. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

3. When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?

• A. Ask the patient to take deep breaths to relax the abdominal musculature.
• B. Consider this finding as normal and proceed with the abdominal assessment.
• C. Increase the amount of strength used when attempting to percuss over the abdomen.
• D. Decrease the amount of strength used when attempting to percuss over the abdomen.

Correct answer: C

Rationale: When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.

4. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

• A. A person of small stature is at increased risk for injury from entrapment.
• B. A history of a previous fall from a bed with raised side rails is significant.
• C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
• D. Creative use of alternative measures indicates respect for the patient's dignity.

Correct answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.

5. A client is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse?

• A. Assist the client to shower as ordered and monitor the site for further changes
• B. Instruct the client to lie prone to allow the site to dry
• C. Place antibiotic ointment and a sterile dressing over the site
• D. Notify the physician for an antibiotic order

Correct answer: A

Rationale: An incision that appears slightly red with a small amount of serous drainage on the first day following surgery is going through a normal healing process. It is important to keep the incision clean. In this case, the nurse should assist the client to shower as ordered to maintain hygiene and monitor for changes in the incision site. Instructing the client to lie prone may not be necessary and could cause discomfort. Applying antibiotic ointment without a specific order is not recommended as it can interfere with the healing process. Notifying the physician for an antibiotic order is premature at this stage since the incision is showing normal signs of healing.

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