Nursing Elites

1. The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

• A. Place the chair at a right angle to the bed on the client's left side before moving.
• B. Assist the client to a standing position, then place the right hand on the armrest.
• C. Have the client place the left foot next to the chair and pivot to the left before sitting.
• D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Correct answer: D

Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.

2. While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

• A. Remove the restraints one at a time
• B. Secure the restraints tightly to prevent movement
• C. Check the restraints every hour
• D. Use leather restraints for additional security

Correct answer: A

Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.

3. A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection, the nurse plans to arrange to increase the client's intake of:

• A. Vitamin C and Zinc
• B. Vitamin B12 and Calcium
• C. Vitamin D and Iron
• D. Vitamin A and Potassium

Correct answer: A

Rationale: The correct answer is A: Vitamin C and Zinc. Vitamin C is essential for collagen synthesis, which is important for wound healing. Zinc plays a crucial role in immune function and also aids in wound healing. Vitamin B12 and Calcium (Choice B) are not directly associated with wound healing properties. Vitamin D and Iron (Choice C) are important for overall health but are not specifically targeted for wound healing. Vitamin A and Potassium (Choice D) do not have direct wound healing properties and are not the best choices to promote wound healing and fight infection.

4. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

• A. Obtain the blood pressure under the same conditions each time
• B. Use a different arm for each measurement
• C. Measure the blood pressure while the client is standing
• D. Take multiple readings at different times of the day

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

5. The healthcare provider is assessing a client who has a chest tube in place following a pneumothorax. Which finding should be reported to the healthcare provider immediately?

• A. Bubbling in the water seal chamber
• B. Drainage greater than 70 ml/hour
• C. Tidaling in the water seal chamber
• D. Absence of breath sounds on the affected side

Correct answer: D

Rationale: The absence of breath sounds on the affected side is a critical finding that may indicate a tension pneumothorax, a life-threatening condition requiring immediate intervention. This situation can lead to a shift of the mediastinum and impaired ventilation. Bubbling in the water seal chamber is an expected finding in a chest tube drainage system and indicates proper functioning. Drainage greater than 70 ml/hour is a concern but does not require immediate reporting unless it continues at a high rate or is associated with other symptoms. Tidaling in the water seal chamber is a normal fluctuation and indicates the chest tube system is patent and functioning correctly.

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