Nursing Elites

1. When turning an immobile bedridden client without assistance, which action best ensures client safety?

• A. Securely grasp the client's arm and leg.
• B. Put bed rails up on the side of bed opposite from the nurse.
• C. Correctly position and use a turn sheet.
• D. Lower the head of the client's bed slowly.

Correct answer: B

Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.

2. The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

• A. To promote oxygenation by removing secretions.
• B. To reduce the amount of air trapped in the lungs.
• C. To increase the amount of carbon dioxide exhaled.
• D. To slow the respiratory rate and improve air exchange.

Correct answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A) and reducing air trapping (B) can be associated benefits to some extent, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics. Slowing the respiratory rate (D) is not the primary purpose of pursed-lip breathing.

3. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

• A. Document the client’s temperature fluctuations
• B. Assess for flushed, warm skin consistently
• C. Measure temperature at regular intervals
• D. Use different sites for temperature measurement

Correct answer: C

Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.

4. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?

• A. Take measures to promote as much comfort as possible.
• B. Report any signs of drug addiction to the nurse immediately.
• C. Wait until the client's pain is gone before assisting with personal care.
• D. This client's pain will be difficult to manage, as the cause is unknown.

Correct answer: A

Rationale: The correct instruction for the unlicensed assistive personnel (UAP) preparing to assist a client with intractable pain is to take measures to promote as much comfort as possible. Intractable pain is resistant to relief, so ensuring comfort during all activities, including a bed bath, is crucial to enhance the client's well-being and quality of care.

5. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?

• A. 13 ml/hour.
• B. 63 ml/hour.
• C. 80 ml/hour.
• D. 125 ml/hour.

Correct answer: B

Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period. Choice A (13 ml/hour) is incorrect as it does not result from the correct calculation. Choice C (80 ml/hour) and Choice D (125 ml/hour) are also incorrect calculations and do not match the correct rate of infusion required.

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