Nursing Elites

1. The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?

• A. the client who most recently rang their call bell
• B. the client who has been waiting the longest for their call bell to be answered
• C. the client who is in the most pain
• D. the client who may have a risk for an airway obstruction

Correct answer: D

Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority. Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.

2. When caring for clients with Buck’s Traction, the major areas of importance should be:

• A. nutrition, elimination, comfort, safety
• B. ROM exercises, transportation
• C. nutrition, elimination, comfort, safety
• D. elimination, safety, isotonic exercises

Correct answer: C

Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications. Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.

3. The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?

• A. Pull the client toward you, and pivot him on the unaffected limb.
• B. Pull the client toward you, and pivot him on the affected limb.
• C. Push the client toward the bed, and pivot him on the affected limb.
• D. Stand the client on both legs, and push him toward the bed.

Correct answer: A

Rationale: When transferring a client from a wheelchair to the bed, the correct procedure is to pull the client toward you, which reduces workload force. By pivoting the client on the unaffected limb, strength is maintained to support the affected limb while moving towards the bed. Choice A is correct because it ensures a safe and effective transfer technique. Choices B, C, and D are incorrect as they involve incorrect positioning and movements that could potentially harm the client or increase the risk of injury. Pulling the client towards you puts less strain on your back and reduces the risk of injury. Pivoting on the unaffected limb ensures better support for the client's affected limb during the transfer process.

4. Which of the following is not considered one of the five rights of medication administration?

• A. client
• B. drug
• C. dose
• D. routine

Correct answer: D

Rationale: The five rights of medication administration are dose, client, drug, route, and time. The correct answer is 'routine' as it is not commonly recognized as one of the essential rights in medication administration. Choice A, client, is necessary to ensure the right medication is administered to the right individual. Choice B, drug, is crucial to confirm the correct medication is given. Choice C, dose, is essential to ensure the right amount of medication is administered. Choice D, routine, is not typically included in the five rights of medication administration and is therefore the correct answer.

5. Which of the following statements indicates adequate dietary understanding in a client with constipation?

• A. "I should decrease my intake of fluids."?
• B. "I should decrease my level of activity."?
• C. "I should increase my intake of apples."?
• D. "I should increase my intake of milk."?

Correct answer: C

Rationale: The correct answer is, "I should increase my intake of apples."? This statement indicates adequate dietary understanding in a client with constipation because apples are a good source of fiber, which helps alleviate constipation. Adequate fiber intake is essential for promoting bowel regularity. Choices A and B are incorrect as decreasing fluids and activity level can worsen constipation. Insufficient fluid intake can lead to hard stools, exacerbating constipation. Decreasing activity can also slow down bowel movements. Choice D is incorrect because milk is not a high-fiber food and may not effectively address constipation. While milk can have a mild laxative effect on some individuals, it is not a primary solution for constipation, especially when compared to high-fiber foods like apples.

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