Nursing Elites

1. Which of the following actions should be taken to use a wide base support when assisting a client to get up in a chair?

• A. Bend at the waist and place arms under the client’s arms and lift
• B. Face the client, bend knees, and place hands on the client’s forearm and lift
• C. Spread the feet apart
• D. Tighten the pelvic muscles

Correct answer: C

Rationale: The correct answer is C: Spread the feet apart. When assisting a client to get up in a chair, it is crucial to use a wide base of support to maintain stability and prevent injuries. Spreading the feet apart provides a broader base, increasing balance and support for both the client and the caregiver. This position helps distribute the weight evenly and allows for better control when assisting the client in moving. Choices A, B, and D are incorrect because bending at the waist, placing arms under the client's arms, tightening pelvic muscles, or placing hands on the client's forearm do not provide the necessary wide base support needed for stability and safety during the transfer process.

2. Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?

• A. Continuity of patient care promotes efficient and cost-effective nursing care.
• B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
• C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
• D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Correct answer: D

Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.

3. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

4. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

• A. Apply a vest restraint if self-extubation is attempted.
• B. Monitor ventilator settings every 8 hours.
• C. Document tube placement in centimeters at the angle of the jaw.
• D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

5. When discussing group treatment and therapy with a client, which characteristic should the nurse include as being a characteristic of a therapeutic group?

• A. The group is organized in an autocratic structure.
• B. The group encourages members to focus on a particular issue
• C. The group must be led by a licensed psychiatrist.
• D. The group encourages clients to form dependent relationships.

Correct answer: B

Rationale: In therapeutic groups, the focus is often on addressing specific issues or topics. This approach allows group members to concentrate on their concerns, share experiences, and work towards common goals. Autocratic structures, mandatory leadership by a licensed psychiatrist, or fostering dependent relationships are not typical characteristics of therapeutic groups.

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