Nursing Elites

1. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?

• A. Neck, shoulders, and chest
• B. Abdomen and groin/perineum
• C. Legs, feet, and web spaces
• D. Back of neck, back, and then buttocks

Correct answer: B

Rationale: In providing a complete bed bath using a bag bath for an unconscious patient, the nurse should follow a specific order. The correct sequence is as follows: Neck, shoulders, and chest; Both arms, both hands, web spaces, and axilla; Abdomen and then groin/perineum; Right leg, right foot, and web spaces; Left leg, left foot, and web spaces; Back of neck, back, and then buttocks. Choice A is incorrect as it does not follow the correct sequence for a bed bath. Choice C is incorrect as it focuses on the lower extremities before addressing the upper body. Choice D is incorrect as it starts with the back of the patient instead of the upper body areas first.

2. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?

• A. Complete a fall-risk assessment.
• B. Educate the client and family about fall risks.
• C. Eliminate safety hazards from the client’s environment.
• D. Ensure the client uses assistive aids in their possession.

Correct answer: C

Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.

3. When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?

• A. Check the client for injuries
• B. Call for additional help
• C. Move the client to a sitting position
• D. Assist the client back to bed

Correct answer: A

Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.

4. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?

• A. Number of staff-induced injuries
• B. Client satisfaction survey
• C. Healthcare-associated infection rate
• D. Rate of needle-stick injuries by nurses

Correct answer: C

Rationale: The correct answer is C: Healthcare-associated infection rate. This measure best indicates the effect of the policy on infection control. By monitoring the healthcare-associated infection rate, it can be determined if the policy of removing acrylic nails has contributed to reducing the risk of infections. Choices A, B, and D are not as directly linked to the outcome of the policy. The number of staff-induced injuries may not be solely due to acrylic nails. Client satisfaction may not be directly impacted by this policy, and needle-stick injuries are more related to a different aspect of healthcare practice.

5. When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?

• A. At the time of admission
• B. The day before the patient is to be discharged
• C. When outpatient therapy is no longer needed
• D. As soon as the patient's discharge destination is known

Correct answer: A

Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.

Similar Questions