Nursing Elites

1. A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

• A. Providing pain management.
• B. Offering emotional support.
• C. Preventing infection.
• D. Initiating IV fluids.

Correct answer: D

Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.

2. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

• A. Ignore the behavior
• B. Reassign the AP
• C. Report the behavior to the manager
• D. Discuss this behavior with the AP while reinforcing expectations

Correct answer: D

Rationale: When a charge nurse observes repeated failure in a staff member's performance, it is essential to address the issue directly. Choice D is the correct answer as it involves discussing the behavior with the assistive personnel (AP) while reinforcing expectations. This approach helps in clarifying the expected standards, setting accountability, and providing an opportunity for improvement. Choices A, B, and C are incorrect. Ignoring the behavior (Choice A) does not address the problem and can lead to continued substandard care. Reassigning the AP (Choice B) may not solve the issue and can potentially transfer the problem to another area. Reporting the behavior to the manager (Choice C) without directly addressing it with the AP first may not promote a constructive approach to resolving the issue.

3. A client is learning to use a cane. What instruction is essential for this client?

• A. Advance the cane and the weaker leg at the same time
• B. Maintain two points of support on the ground at all times
• C. Use the cane on the weaker side for better support
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction for a client learning to use a cane is to maintain two points of support on the ground at all times. This ensures better stability and reduces the risk of falls. Choice A is incorrect because advancing the cane and the weaker leg simultaneously may lead to imbalance. Choice C is incorrect because the cane should be used on the stronger side to provide support. Choice D is incorrect because there is no specific measurement for advancing the cane with each step, and the focus should be on maintaining stability.

4. How can a healthcare professional reduce the risk of falls in elderly patients?

• A. Encourage the use of assistive devices.
• B. Clear walkways.
• C. Ensure proper lighting.
• D. All of the above.

Correct answer: D

Rationale: All of these interventions are crucial in reducing the risk of falls in elderly patients. Encouraging the use of assistive devices helps provide support and stability, clearing walkways minimizes tripping hazards, and ensuring proper lighting enhances visibility and reduces the chances of falls. Therefore, choosing 'All of the above' is the most appropriate answer as each intervention plays a significant role in fall prevention.

5. What is the nurse's responsibility when managing a physically assaultive client?

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control
• D. Clear the area of other clients

Correct answer: C

Rationale: The correct answer is C: Restore the client's self-control. When managing a physically assaultive client, the nurse's responsibility is to help the client regain control over their actions and emotions. This is crucial in preventing harm to themselves and others. Restricting the client to the room (Choice A) may escalate the situation and is not a therapeutic approach. Placing the client under one-to-one supervision (Choice B) is important for safety but does not address the root cause of the behavior. Clearing the area of other clients (Choice D) is necessary for safety but does not directly address the client's self-control. Therefore, the priority in managing an assaultive client is to focus on restoring their self-control.

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