Nursing Elites

1. 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.

2. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

• A. Notify the charge nurse that a medication error occurred.
• B. Submit a medication variance report to the supervisor.
• C. Document the events that occurred in the nurse's notes.
• D. Discard the original medication administration record.

Correct answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care. Notifying the charge nurse or submitting a medication variance report may not be necessary as the situation was managed appropriately, and discarding the original medication administration record is not recommended as it is part of the client's medical record and should be kept for documentation purposes.

3. You are assigned to teach a student how to suction an adult patient with a tracheostomy. Which of the following actions by the student would be incorrect?

• A. Pre-oxygenating the patient with a Resuscibag at 100% O2 several times before suctioning.
• B. Maintaining wall suction pressure at 110-150 mmHg.
• C. Not suctioning for greater than 10-15 seconds at a time.
• D. Applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning.

Correct answer: D

Rationale: The incorrect action by the student is applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning. This technique can cause trauma to the tracheal walls, increasing the risk of injury to the patient. It is essential to perform suctioning gently and without rotation to prevent complications in patients with a tracheostomy. Pre-oxygenating the patient, maintaining appropriate suction pressure, and limiting suctioning time are all correct actions when suctioning a patient with a tracheostomy.

4. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?

• A. Explain the potential respiratory issues associated with morphine use.
• B. Educate the family on assessing the effectiveness of analgesics.
• C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
• D. Provide the client with a schedule for around-the-clock prescribed analgesic use.

Correct answer: D

Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.

5. The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to the daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine currently followed.

Correct answer: D

Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.

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