Nursing Elites

1. A client with a history of falls is being admitted to the unit. What intervention should the nurse implement first?

• A. Increase the client's medication to ensure they don't fall.
• B. Use bed alarms to monitor the client's movements.
• C. Encourage the client to use a walker for mobility.
• D. Assign the client to a nursing assistant for supervision.

Correct answer: B

Rationale: The correct answer is B: 'Use bed alarms to monitor the client's movements.' When a client with a history of falls is admitted, the nurse's initial intervention should focus on fall prevention measures. Using bed alarms to monitor the client's movements can help alert the healthcare team if the client attempts to get out of bed and reduce the risk of falls. Choice A is incorrect because increasing medication should not be the first intervention as it may not address the underlying causes of falls and can have adverse effects. Choice C may be appropriate but is not the priority over implementing safety measures like bed alarms. Choice D is incorrect as assigning the client to a nursing assistant for supervision alone may not be as effective as utilizing bed alarms for continuous monitoring.

2. A client has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?

• A. Lemon sherbet
• B. Milkshake
• C. Vanilla ice cream
• D. Grape juice

Correct answer: D

Rationale: Grape juice is the correct choice for a clear liquid diet because it is a liquid that is transparent and does not contain any solid particles. Lemon sherbet, milkshake, and vanilla ice cream are not appropriate for a clear liquid diet as they all contain solid particles or are not in liquid form.

3. A nurse is planning a staff education program to review nursing interventions for clients who have kidney failure. Which of the following sources should the nurse identify as the best resource for obtaining evidence-based information?

• A. The advice of an expert nephrology nurse
• B. Retrospective chart reviews
• C. Facility critical pathway
• D. A recent peer-reviewed nursing research article

Correct answer: D

Rationale: A peer-reviewed nursing research article is the best resource for obtaining evidence-based information because it provides the most current and reliable data on nursing interventions. Choice A, the advice of an expert nephrology nurse, may be helpful but could be based on individual experience rather than the latest research. Retrospective chart reviews (Choice B) focus on past cases and may not reflect current best practices. Facility critical pathways (Choice C) offer standardized care plans but may not always incorporate the most up-to-date evidence-based practices.

4. A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

• A. Discuss whether family members will assist with postoperative care
• B. Review the client's current home environment
• C. Identify the client's usual coping mechanisms
• D. Determine what the client knows about the surgery

Correct answer: D

Rationale: In the preoperative phase, determining what the client knows about the surgery is the priority. This action helps address misconceptions, provide necessary information, and ensure the client's understanding and cooperation. Choices A, B, and C are important aspects of preoperative care but assessing the client's knowledge about the surgery takes precedence to alleviate fears, enhance communication, and optimize outcomes.

5. The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?

• A. Repeat handwashing using antiseptic soap.
• B. Inform the healthcare provider and recruit another nurse to assist.
• C. Extend the handwashing procedure to 5 minutes.
• D. Rinse and dry hands and begin assisting the healthcare provider.

Correct answer: A

Rationale: The correct answer is A. The sink is considered a contaminated area. When hand hygiene is compromised during the process, it is essential to repeat handwashing using antiseptic soap to ensure proper hygiene. Choice B is incorrect because the situation can be managed by proper handwashing. Choice C is incorrect as extending the handwashing procedure to 5 minutes is not necessary in this scenario. Choice D is incorrect as the hands need to be properly cleaned before assisting the healthcare provider.

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