Nursing Elites

1. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

• A. Determine if the expected outcomes were realistic
• B. Obtain current client data to compare with expected outcomes
• C. Modify the nursing interventions to achieve the client’s goals
• D. Review related professional standards of care

Correct answer: A

Rationale: After reviewing the expected outcomes identified in the plan of care, the nurse's next step should be to determine if these outcomes were realistic. This assessment helps in understanding if the goals set were achievable and appropriate for the client's condition before proceeding to compare them with current client data or modifying nursing interventions. By verifying the realism of the expected outcomes, the nurse ensures a solid foundation for further evaluation and adjustment of the care plan. Option B is incorrect because obtaining current client data comes after assessing the realism of the expected outcomes. Option C is incorrect because modifying nursing interventions should be based on the assessment of the expected outcomes' realism. Option D is incorrect as reviewing professional standards of care is important but not the immediate next step after assessing the expected outcomes' realism.

2. A male client with unstable angina needs a cardiac catheterization. The healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

• A. Answer the client’s specific questions with a short, understandable explanation
• B. Postpone the procedure until the client understands the risks and benefits
• C. Call the client’s next of kin and ask them to provide verbal consent
• D. Page the healthcare provider to return and provide additional explanation

Correct answer: D

Rationale: The nurse should ask the healthcare provider to return and provide further explanation to the client. The healthcare provider is the one who can address the risks and benefits of the procedure in detail, ensuring the client receives accurate information before providing consent.

3. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.

4. 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.

5. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

• A. Tell the UAP to use a larger cuff at the next scheduled assessment.
• B. Reassess the client's blood pressure using a larger cuff.
• C. Have the unit educator review this procedure with the UAPs.
• D. Teach the UAP the correct technique for assessing blood pressure.

Correct answer: B

Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.

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