Nursing Elites

1. A client with dementia is at risk of falls. Which intervention should the nurse implement to ensure safety?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm to notify staff when the client tries to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff when the client tries to leave the bed. This intervention helps prevent falls while still allowing some freedom of movement. Choice A is incorrect because using restraints can lead to complications and is considered a form of restraint which should be avoided. Choice C is not suitable for a client at high risk of falls due to dementia as it may increase the risk of falls. Choice D is not recommended as raising all four side rails can be considered a form of physical restraint and may not be the best approach to prevent falls in a client with dementia.

2. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hr following surgery.
• B. Give cromolyn nebulizer solution every 6 hr.
• C. Apply a warm compress to the operative site every 4 hr.
• D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

3. What is an important consideration when administering a blood transfusion?

• A. Ensure the blood is compatible with the recipient's blood type
• B. Warm the blood to body temperature before administration
• C. Check the blood for clots before administration
• D. Ensure the recipient eats before the transfusion

Correct answer: A

Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.

4. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?

• A. The child is placed in a private room
• B. The staff removes a toy from the child's bed and takes it to the nurse's station
• C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack
• D. The staff uses standard precautions

Correct answer: A

Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.

5. What is the proper technique for measuring blood pressure manually?

• A. Use a stethoscope to listen for the Korotkoff sounds
• B. Ensure the patient is seated with the arm supported
• C. Use a manual sphygmomanometer
• D. Deflate the cuff slowly while listening to the heartbeat

Correct answer: A

Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.

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