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. Which nonverbal action should be implemented to demonstrate active listening?

• A. Sit facing the individual.
• B. Cross arms and legs.
• C. Avoid eye contact.
• D. Lean back in the chair.

Correct answer: A

Rationale: To demonstrate active listening effectively, it is essential to display open and engaging body language. Sitting facing the individual helps convey attentiveness and a willingness to listen. Maintaining eye contact further enhances the connection and shows respect and interest in the conversation. Crossing arms and legs can create a barrier and signal defensiveness or disinterest. Avoiding eye contact may suggest a lack of engagement or attentiveness. Leaning back in the chair can indicate relaxation but might be perceived as disengagement. Therefore, the most appropriate nonverbal action to demonstrate active listening is to sit facing the individual and maintain eye contact.

3. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?

• A. Do not massage any reddened areas.
• B. Encourage passive range of motion exercises on extremities.
• C. Position the client laterally, supine, and prone in sequence.
• D. Gently lift the client when moving into a desired position.

Correct answer: D

Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.

4. When faced with caring for a close friend in a professional setting, which action should the staff member take first?

• A. Notify the friend that all medical information will be kept confidential.
• B. Explain the relationship to the charge nurse and ask for reassignment.
• C. Approach the client and ask if the assignment is uncomfortable.
• D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.

5. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

• A. Document the client's request in the medical record.
• B. Ask the client if this decision has been discussed with his healthcare provider.
• C. Inform the client that a written, notarized advance directive is required to withhold resuscitation efforts.
• D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Correct answer: B

Rationale: When a client expresses the desire to not be resuscitated, it is essential to inquire if this decision has been discussed with their healthcare provider. This is important to ensure that the client's wishes are appropriately documented and legally binding through the healthcare provider's guidance. It is crucial that healthcare decisions, especially those involving life-saving measures, are well-communicated and documented to respect the client's autonomy and ensure their wishes are honored. Option A is not the best action as it does not address the need to verify discussion with the healthcare provider. Option C is incorrect as it overemphasizes the need for a notarized advance directive, which may not be immediately feasible or necessary in this urgent situation. Option D is not the most appropriate action at this time since the immediate focus should be on clarifying if the decision has been communicated with the healthcare provider.

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