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. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low carbohydrate and high protein meals
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

3. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper, and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

• A. Establish a toileting schedule to decrease episodes of incontinence
• B. Complete a functional assessment of the client’s self-care abilities
• C. Apply a barrier ointment to intact areas that may be exposed to moisture
• D. Determine the size and depth of skin breakdown over the sacral area

Correct answer: D

Rationale: The initial step the nurse should take when faced with skin breakdown over the sacral area of the client is to determine the size and depth of the affected area. Assessing and documenting these aspects are crucial before initiating any treatment. This evaluation will guide the nurse in developing an appropriate care plan to address the skin breakdown effectively. Options A, B, and C are not the first steps to take in this situation. While establishing a toileting schedule and completing a functional assessment are important, assessing the size and depth of the skin breakdown is the priority to initiate proper treatment. Applying a barrier ointment without assessing the extent of the breakdown may not address the underlying issue effectively.

4. Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?

• A. Sensory pattern, area, intensity, and nature of the pain.
• B. Identification of trigger points through palpation and manual pressure on painful areas.
• C. Current schedule and total dosages of medications used for breakthrough pain.
• D. Assessment of sympathetic responses indicative of acute pain onset.

Correct answer: A

Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.

5. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?

• A. Administer sublingual nitroglycerin
• B. Obtain a 12-lead electrocardiogram (ECG)
• C. Apply oxygen via nasal cannula
• D. Initiate continuous cardiac monitoring

Correct answer: C

Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.

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