Nursing Elites

1. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?

• A. Re-assess the patient.
• B. Complete an incident report.
• C. Notify the healthcare provider.
• D. Do nothing, as no harm has occurred.

Correct answer: C

Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.

2. 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.

3. A nursing instructor is observing a nursing student practicing standard precautions. Which observation by the instructor indicates a need for further teaching?

• A. The nursing student wears a gown to change the bed of an incontinent client.
• B. The nursing student washes hands before making contact with the client.
• C. The nursing student washes her hands before glove removal after emptying a Foley bag.
• D. The nursing student changes gloves between tasks and procedures.

Correct answer: C

Rationale: The correct answer is C. The nursing student washing her hands before glove removal after emptying a Foley bag indicates a need for further teaching. Hands should be washed after glove removal to maintain proper infection control. Choice A is correct as wearing a gown when changing the bed of an incontinent client is a standard precaution. Choice B is correct as washing hands before making contact with the client is a good practice. Choice D is correct as changing gloves between tasks and procedures is a standard precaution to prevent the spread of infection.

4. The family member is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings?

• A. The family member saves part of the dressing because it is clean.
• B. The family member places the used dressings in a plastic bag.
• C. The family member removes gloves and gathers items for disposal.
• D. The family member wraps the used dressing in toilet tissue before placing it in the trash.

Correct answer: B

Rationale: The correct way to manage contaminated dressings is to place them in plastic bags for proper disposal. This helps prevent the spread of infection. Choice A is incorrect because saving part of the dressing is not a recommended practice. Choice C is not directly related to managing contaminated dressings. Choice D is incorrect as wrapping the used dressing in toilet tissue is not the appropriate way to dispose of contaminated dressings.

5. A client with cirrhosis and ascites requires a care plan. Which intervention should the nurse include?

• A. Increase the client's sodium intake
• B. Increase the client's saturated fat intake
• C. Decrease the client's carbohydrate intake
• D. Decrease the client's fluid intake

Correct answer: D

Rationale: In cirrhosis with ascites, decreasing fluid intake is crucial to manage the condition. This helps prevent further fluid accumulation in the abdomen. Increasing sodium intake (Choice A) can worsen fluid retention and edema. Increasing saturated fat intake (Choice B) is not recommended as it can contribute to liver damage. Decreasing carbohydrate intake (Choice C) is not directly related to managing ascites in cirrhosis.

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