Nursing Elites

1. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:

• A. sprain.
• B. strain.
• C. subluxation.
• D. dislocation.

Correct answer: B

Rationale: A sprain is the correct term for the excessive stretching of a ligament, which is what happens when a ligament is pulled. A strain involves muscle tissue. Subluxation refers to a partial dislocation, and dislocation is a complete displacement of bones in a joint. In this case, since it's a pulled ligament, the most appropriate term is a sprain.

2. When are pressure ulcers most likely to occur?

• A. when clients are left in one position in bed for extended periods of time.
• B. when clients are underweight.
• C. when clients are overweight.
• D. only in underweight and overweight clients.

Correct answer: A

Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client. Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.

3. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

• A. Rechecking the pulse oximetry reading
• B. Calling the respiratory therapist
• C. Calling the healthcare provider
• D. Oxygenating the client with 100% oxygen

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

4. When are standard walkers typically used?

• A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
• B. When clients have poor balance, have a broken leg, or have experienced amputation.
• C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
• D. When clients have poor balance, have an autoimmune disease, or have weak arms.

Correct answer: C

Rationale: Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.

5. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?

• A. Ignoring the situation
• B. Documenting the problem in the nursing assistant's personnel file
• C. Asking other staff members to cover for the nursing assistant
• D. Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures

Correct answer: D

Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.

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