Nursing Elites

1. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

• A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
• B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
• C. Assist the client to a standing position by gently lifting upward underneath the axillae.
• D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Correct answer: B

Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.

2. A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?

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

Correct answer: C

Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.

3. Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client’s plan of care?

• A. Recent serum hemoglobin level of 16 g/dL
• B. Opioid analgesic received one hour ago
• C. Stooped posture with an unsteady gait
• D. Expressed feelings of depression

Correct answer: B

Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

4. A client being discharged with a prescription for the bronchodilator theophylline is instructed to take three doses of the medication each day. Since timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?

• A. 9 a.m., 1 p.m., and 5 p.m.
• B. 8 a.m., 4 p.m., and midnight.
• C. Before breakfast, before lunch, and before dinner.
• D. With breakfast, with lunch, and with dinner.

Correct answer: B

Rationale: Theophylline should be administered on a regular around-the-clock schedule to provide the best bronchodilating effect and reduce the potential for adverse effects. The correct dosing schedule of 8 a.m., 4 p.m., and midnight ensures that the client receives consistent dosing throughout the day. Other options do not provide the necessary around-the-clock coverage. It's important to note that food may affect the absorption of the medication, which is why the dosing schedule should not be tied to meal times.

5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client’s care.
• B. Provide the wife with information about hospice.
• C. Encourage the wife to visit during and after painful treatments are completed.
• D. Refer the wife to a support group for family members of those dying of cancer.

Correct answer: A

Rationale: During this challenging time of dealing with a terminal cancer diagnosis, involving the wife in the care process can be highly beneficial. By asking the wife how she would like to participate in the client’s care, it allows her to feel more in control and connected. This approach fosters a collaborative care environment, ensuring that the wife's preferences and needs are taken into consideration. Providing information about hospice (choice B) may be premature at this stage and could potentially overwhelm the family. Encouraging the wife to visit during and after painful treatments (choice C) may not address her need for involvement in decision-making. Referring the wife to a support group (choice D) is helpful but may not directly involve her in the care process of her husband.

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