Nursing Elites

1. The healthcare provider is preparing an older client for discharge. Which method is best for the provider to use when evaluating the client's ability to perform a dressing change at home?

• A. Determine the client's feelings about changing the dressing.
• B. Ask the client to write a description of the procedure.
• C. Have a family member evaluate the client's ability to change the dressing.
• D. Observe the client performing an unassisted dressing change.

Correct answer: D

Rationale: Direct observation of the client performing the skill is the most effective method to assess the client's ability to independently change the dressing. This allows the healthcare provider to evaluate the client's technique, understanding, and readiness to perform the task at home. Choices A, B, and C are not as reliable as directly observing the client performing the dressing change. Determining the client's feelings may not accurately reflect their ability, asking the client to write about the procedure may not demonstrate their practical skills, and having a family member evaluate might not provide an accurate assessment of the client's ability.

2. 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.

3. What is the main purpose of the working phase of the nurse-patient relationship?

• A. Establish a formal or informal contract that addresses the patient's problems.
• B. Implement nursing interventions that are designed to achieve expected patient outcomes.
• C. Develop rapport and trust so the patient feels supported, and the initial plan can be identified.
• D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.

Correct answer: B

Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship. Choices A, C, and D are incorrect as they describe activities more aligned with other phases of the nurse-patient relationship, such as orientation and introductory phases.

4. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?

• A. Obtain informed consent from the client for the PRBC transfusion
• B. Review the client’s medical history for a history of transfusion reactions
• C. Assess the client’s baseline vital signs before starting the transfusion
• D. Verify the blood type and crossmatch with another licensed nurse

Correct answer: D

Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.

5. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's weight increases by 1 kg in 24 hours.
• B. The client's peritoneal effluent is cloudy.
• C. The client's blood pressure is 140/90 mm Hg.
• D. The client's peritoneal effluent is clear and pale yellow.

Correct answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

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