Nursing Elites

1. What is the primary purpose of turning and repositioning an immobile patient every 2 hours?

• A. To improve circulation and relieve pressure.
• B. To prevent contractures and muscle atrophy.
• C. To prevent skin breakdown and pressure ulcers.
• D. To improve respiratory function and prevent pneumonia.

Correct answer: C

Rationale: The primary purpose of turning and repositioning an immobile patient every 2 hours is to prevent skin breakdown and pressure ulcers. Prolonged immobility can lead to pressure ulcers, making this a crucial nursing intervention. Choice A is incorrect because while turning can help improve circulation and relieve pressure, the primary purpose is to prevent skin breakdown. Choice B is incorrect as preventing contractures and muscle atrophy is important but not the primary purpose of turning. Choice D is incorrect as improving respiratory function and preventing pneumonia are not directly related to turning and repositioning for skin integrity.

2. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?

• A. Encourage physical activity to reduce withdrawal symptoms
• B. Administer diazepam to prevent seizures
• C. Monitor for signs of dehydration
• D. Encourage the client to verbalize their feelings

Correct answer: B

Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.

3. What should be done to ensure safety during the transfer of a patient with limited mobility?

• A. Have the patient use a gait belt for support.
• B. Encourage the patient to hold onto a walker.
• C. Lock the wheels on the bed and wheelchair.
• D. Ask the patient to transfer independently.

Correct answer: C

Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.

4. A health care provider asks the nurse to administer a medication with a dosage significantly higher than usual. What is the nurse's first action?

• A. Administer the medication as ordered.
• B. Question the provider and verify the dose.
• C. Administer half the dosage as a precaution.
• D. Refuse to administer the medication without clarification.

Correct answer: B

Rationale: When a health care provider orders a medication with a dosage significantly higher than usual, the nurse's initial action should be to question the provider and verify the dose. This is crucial to ensure patient safety and prevent medication errors. Administering the medication as ordered (Choice A) without clarification could potentially harm the patient if there was an error in the prescription. Administering half the dosage as a precaution (Choice C) is not a safe practice as it deviates from the prescribed order. Refusing to administer the medication without clarification (Choice D) is important, but the first step should be to seek clarification from the provider to prevent any unnecessary delays in patient care.

5. A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

• A. Request a prescription for the insertion of an indwelling urinary catheter
• B. Check the client's skin every 8 hours for signs of breakdown
• C. Apply a moisture barrier ointment to the client's skin
• D. Clean the client's skin and perineum with hot water after each episode of incontinence

Correct answer: C

Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.

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