Nursing Elites

1. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

• A. Check the bath water temperature.
• B. Shut the bathroom door.
• C. Ensure that the client has voided.
• D. Provide extra towels.

Correct answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

2. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

• A. Autopsy of the body is prohibited.
• B. Blood transfusions are forbidden.
• C. Alcohol use in any form is not allowed.
• D. A vegetarian diet must be followed.

Correct answer: B

Rationale: The correct answer is B. In the Jehovah's Witness religion, blood transfusions are forbidden due to their beliefs. Autopsy prohibition is in Judaism, while alcohol and drug use is not allowed in Buddhism. While some sects are vegetarian, the critical concern in nursing care for Jehovah's Witnesses is respecting their prohibition of blood transfusions.

3. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

• A. Check for a blood return.
• B. Reposition the client's arm.
• C. Remove the IV site dressing.
• D. Flush the lock with saline.

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

4. 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.

5. The client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

• A. Observe the appearance of the skin under the ice pack.
• B. Instruct the client regarding the importance of the covering.
• C. Reapply the covering after filling it with fresh ice.
• D. Ask the client how long the ice pack was applied to the skin.

Correct answer: A

Rationale: The primary action for the nurse is to assess the skin under the ice pack to check for any potential thermal injury. This assessment is crucial to ensure the client's safety. Once the skin assessment is done and no harm is found, the nurse can proceed with other necessary actions such as providing instructions to the client or replacing the covering with fresh ice.

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