Nursing Elites

1. When transferring a client to a long-term care facility, what information should the nurse include in the handoff report?

• A. Frequency of previous vital sign measurements
• B. Number of family members who have visited
• C. Time of the client's last bath
• D. Effectiveness of the last dose of pain medication

Correct answer: D

Rationale: The correct answer is D: 'Effectiveness of the last dose of pain medication.' When transferring a client to a long-term care facility, it is crucial to provide information on the effectiveness of the last dose of pain medication to ensure continuity of care and appropriate pain management. This information helps the receiving facility understand the client's current pain status and plan future interventions accordingly. Choices A, B, and C are less relevant for the handoff report in this scenario. The frequency of previous vital sign measurements may be important, but the immediate effectiveness of pain medication takes precedence. The number of family members who have visited and the time of the client's last bath are not as critical for the receiving facility's immediate care planning compared to pain management details.

2. The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?

• A. Restrict the patient's mobility as much as possible.
• B. Realize the patient is unable to move extremities.
• C. Move all the patient's extremities.
• D. Further assess the patient.

Correct answer: D

Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.

3. A client who had a myocardial infarction (MI) 2 days ago has many questions about this condition. What area is a priority for the nurse to discuss at this time?

• A. Daily needs and concerns
• B. The overview of cardiac rehabilitation
• C. Medication and diet guidelines
• D. Activity and rest guidelines

Correct answer: A

Rationale: Addressing the client's daily needs and concerns is a priority to help alleviate anxiety and ensure the client understands the immediate post-MI care. Daily needs and concerns encompass basic aspects like comfort, hygiene, emotional support, and overall well-being, which are crucial in the early recovery phase post-MI. Discussing cardiac rehabilitation, medication and diet guidelines, or activity and rest guidelines are important topics but addressing immediate personal needs and concerns takes precedence to establish a supportive and informative care environment.

4. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

• A. Why don’t we now have the client turn back to the left side.
• B. That was done correctly. Did you have any problems with the insertion?
• C. Let’s check to see if the suppository is in far enough.
• D. Did you feel any stool in the intestinal tract?

Correct answer: B

Rationale: The appropriate comment by the nurse is to affirm the correct technique while offering support and checking for any issues during the insertion.

5. A client is contemplating retirement and expresses uncertainty about wanting to retire. Which of the following responses should the nurse make?

• A. Let’s talk about how the change in your job status will affect you.
• B. Have you considered the financial implications of retirement?
• C. What are your thoughts on retirement and how it may impact your life?
• D. Would you like to discuss potential activities you could engage in during retirement?

Correct answer: A

Rationale: Choosing option A, 'Let’s talk about how the change in your job status will affect you,' is the most appropriate response in this scenario. By discussing how retirement might affect the client, the nurse can address the client's concerns and emotions about the impending change. Option B, 'Have you considered the financial implications of retirement?' is not the best response as it focuses solely on financial aspects and does not address the client's emotional readiness for retirement. Option C, 'What are your thoughts on retirement and how it may impact your life?' is more open-ended and may not address the immediate concerns of the client expressing uncertainty. Option D, 'Would you like to discuss potential activities you could engage in during retirement?' assumes the client is certain about retiring and focuses on activities rather than addressing the client's feelings of uncertainty.

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