Nursing Elites

1. What is the most important nursing action when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

2. A nurse is caring for a client with Alzheimer's disease who wanders frequently. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a well-lit area to reduce wandering.
• B. Ensure that the client wears an identification bracelet at all times.
• C. Keep the client's bed in the lowest position.
• D. Use physical restraints to prevent wandering.

Correct answer: B

Rationale: The correct answer is to ensure that the client wears an identification bracelet at all times. This intervention helps staff recognize clients who wander and ensures their safety. Placing the client in a well-lit area (Choice A) may be helpful in some cases but does not directly address the issue of wandering. Keeping the client's bed in the lowest position (Choice C) is important for fall prevention but is not directly related to wandering behavior. Using physical restraints (Choice D) is not recommended as the first-line intervention for wandering and should be avoided due to ethical concerns and potential risks.

3. A nurse is teaching a client who is at 10 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make?

• A. This test will confirm whether your baby has a genetic disorder.
• B. Amniocentesis is used to assess your baby's lung maturity.
• C. You should not feel any pain during this procedure.
• D. This test will assess the amount of amniotic fluid around your baby.

Correct answer: A

Rationale: The correct answer is A because amniocentesis is a procedure that confirms genetic disorders by analyzing the amniotic fluid surrounding the baby. Choice B is incorrect because amniocentesis is not used to assess lung maturity. Choice C is incorrect because some discomfort or pain may be felt during the procedure. Choice D is incorrect because amniocentesis does not primarily assess the amount of amniotic fluid around the baby.

4. A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take?

• A. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice
• B. Tell staff to explain procedures to clients before obtaining informed consent
• C. Instruct unit staff to share personal experiences to help clients make decisions
• D. Develop a system for staff members to report safety concerns in the client care environment

Correct answer: D

Rationale: The correct answer is D. Developing a system for staff members to report safety concerns in the client care environment is crucial to promoting client advocacy and ensuring client safety. This action empowers staff to identify and address potential safety issues, ultimately enhancing the quality of care provided. Choices A, B, and C are incorrect. Choice A suggests implementing paternalism, which involves making decisions for clients without their input, contradicting the principles of client advocacy. Choice B focuses on informed consent procedures, which are important but do not directly relate to promoting client advocacy among staff. Choice C, sharing personal experiences, may not always align with professional boundaries and can potentially bias clients' decision-making processes.

5. A client with osteoporosis is being taught by a nurse about preventing bone loss. Which of the following instructions should the nurse include?

• A. Take a calcium supplement once a day.
• B. Avoid weight-bearing exercises.
• C. Walk for 30 minutes 3 times per week.
• D. Increase intake of high-phosphorus foods.

Correct answer: C

Rationale: The correct answer is C: 'Walk for 30 minutes 3 times per week.' Walking is a weight-bearing exercise that helps prevent bone loss and improve overall health in clients with osteoporosis. Option A is incorrect because while calcium is essential for bone health, simply taking a supplement is not sufficient for preventing bone loss. Option B is incorrect because weight-bearing exercises are actually beneficial for improving bone density and strength. Option D is incorrect because high-phosphorus foods do not play a significant role in preventing bone loss in osteoporosis.

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