Nursing Elites

1. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

• A. Clean sutures along the incision site.
• B. Grasp the knot of the sutures with forceps.
• C. Cut the sutures close to the skin on one side.
• D. Pull out the sutures with forceps in one piece.

Correct answer: A

Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.

2. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

• A. Help the client write down the questions to ask the provider, so that the client doesn’t forget
• B. Reassure the client that everything will be explained
• C. Explain the procedure in detail yourself
• D. Direct the client to search for information online

Correct answer: A

Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.

3. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

4. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

• A. Place the wheelchair at a 45-degree angle to the bed
• B. Position the wheelchair parallel to the bed
• C. Place the wheelchair in front of the bed
• D. Have the client stand and pivot into the wheelchair

Correct answer: A

Rationale: Placing the wheelchair at a 45-degree angle to the bed is the correct technique for transferring a client who is unable to walk from bed to a wheelchair. This positioning facilitates a safer and easier transfer by providing more space for maneuvering and reducing the distance the client needs to be moved. Positioning the wheelchair parallel to the bed (Choice B) may make the transfer more challenging due to limited space and a longer distance to move the client. Placing the wheelchair in front of the bed (Choice C) may not provide an optimal angle for the transfer. Having the client stand and pivot into the wheelchair (Choice D) is not appropriate for a client who is unable to walk and could increase the risk of falls or injuries during the transfer.

5. A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?

• A. “I will first dissolve the tablet in water.”
• B. “I will insert the tablet between my cheek and teeth.”
• C. “I will place the tablet under my tongue.”
• D. “I will chew the tablet.”

Correct answer: B

Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.

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