Nursing Elites

1. Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?

• A. All 4 side rails up, wheels locked, bed closest to door
• B. Lower side rails up, bed facing the doorway
• C. Knees bent, head slightly elevated, bed in the lowest position
• D. Bed in the lowest position, wheels locked, place bed against the wall

Correct answer: D

Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.

2. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?

• A. Cut the child's hair short to remove the nits
• B. Apply warm soaks to the head twice daily
• C. Wash the child's linen and clothing in a bleach solution
• D. Application of pediculicides

Correct answer: D

Rationale: Pediculicides are the recommended treatment for lice and should be used to eliminate the infestation.

3. A nurse is reinforcing teaching with a client about dietary choices for celiac disease. Which of the following menu choices selected by the client indicates an understanding of the teaching?

• A. Hamburger on a wheat bun
• B. Baked chicken and potato chips
• C. Bacon, lettuce, and tomato sandwich on rye toast
• D. Beef and barley soup with crackers

Correct answer: B

Rationale: The correct answer is B because baked chicken and potato chips are gluten-free options suitable for a client with celiac disease. Choice A, a hamburger on a wheat bun, contains gluten, which is harmful to individuals with celiac disease. Choice C, a bacon, lettuce, and tomato sandwich on rye toast, also contains gluten. Choice D, beef and barley soup with crackers, includes gluten from the barley and crackers, making it unsuitable for someone with celiac disease.

4. A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?

• A. Determine the client's usual pattern of activity.
• B. Assist the client in developing a healthy eating plan.
• C. Encourage the client to join a support group.
• D. Provide the client with a list of signs and symptoms to report to the provider.

Correct answer: A

Rationale: Assessing the client's usual pattern of activity is crucial as it helps the nurse understand the client's current level of physical activity, any limitations, and areas needing improvement. This information is essential to create a safe and effective exercise plan tailored to the client's specific needs. Choice B, assisting the client in developing a healthy eating plan, is important but not the first step when the client's immediate goal is to start an exercise program. Encouraging the client to join a support group may be beneficial for motivation and emotional support but is not the priority at this stage. Providing a list of signs and symptoms to report to the provider is important for client education but is not the initial step when the client expresses a desire to begin an exercise program.

5. In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

• A. Neurological status
• B. Cardiac status
• C. Respiratory status
• D. Gastrointestinal status

Correct answer: B

Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.

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