Nursing Elites

1. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

2. The healthcare professional is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the healthcare professional include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: To maintain patency and ensure proper medication delivery, water should be instilled into the feeding tube between administering the two medications. This helps prevent clogging of the tube and ensures that both medications are delivered effectively without interference from remnants of the previous medication. Diluting the medications with sterile water before administration (choice A) is unnecessary and may alter the medication concentration. Mixing the medications in one syringe (choice B) could lead to interactions or chemical reactions between the medications. Withdrawing fluid from the tube before instilling each medication (choice D) is not required and may increase the risk of tube displacement or misplacement.

3. The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?

• A. The client reports pain at the IV site
• B. The client’s heart rate is irregular
• C. The client has swelling at the IV site
• D. The client’s blood pressure is elevated

Correct answer: B

Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.

4. The caregiver learns the use of a gait belt from the nurse for a woman with right-sided weakness. The caregiver demonstrates the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?

• A. Standing on the woman's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the woman's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the woman, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the woman, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: The correct answer is B. Standing on the weak side of the client and holding the gait belt from the back provides better security and support during ambulation, reducing the risk of falls. This positioning allows the caregiver to offer stability and assistance without interfering with the client's movement, ensuring safe ambulation for the client with right-sided weakness. Choices A, C, and D are incorrect because they do not provide the optimal support and security needed for a client with right-sided weakness. Standing on the weak side and holding the gait belt from the back is the most effective way to assist the client while minimizing the risk of falls.

5. 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.

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