Nursing Elites

1. When assessing the skin of an immobilized patient, what should the nurse do?

• A. Assess the skin every 4 hours.
• B. Limit the amount of fluid intake.
• C. Use a standardized tool such as the Braden Scale.
• D. Have special times for inspection to not interrupt routine care.

Correct answer: C

Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.

2. A nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Nonmaleficence

Correct answer: D

Rationale: The correct answer is D, Nonmaleficence. Nonmaleficence refers to the principle of 'do no harm.' In this scenario, questioning a potentially harmful prescription for a client with advanced age and unstable status aligns with the principle of nonmaleficence, as the nurse is advocating for the client's safety and well-being. Choice A, Fidelity, refers to being faithful and keeping promises, which is not directly related to the situation described. Choice B, Autonomy, pertains to respecting a patient's right to make their own decisions, which is not the focus of the nurse questioning the prescription. Choice C, Justice, involves fairness and equal treatment, which is not the primary ethical principle at play in this situation.

3. The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

• A. Place the chair at a right angle to the bed on the client's left side before moving.
• B. Assist the client to a standing position, then place the right hand on the armrest.
• C. Have the client place the left foot next to the chair and pivot to the left before sitting.
• D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Correct answer: D

Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.

4. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

• A. Breath sounds
• B. Client’s history of smoking
• C. Current medication list
• D. Client’s family history of respiratory illness

Correct answer: A

Rationale: In a client with pneumonia, assessing breath sounds is crucial as it provides immediate information about the client's respiratory status. Changes in breath sounds could indicate complications like fluid accumulation or worsening pneumonia. While the client's history of smoking (Choice B), current medication list (Choice C), and family history of respiratory illness (Choice D) are important factors to consider, they are not as urgent or directly related to the client's immediate condition as assessing breath sounds.

5. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

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