Nursing Elites

1. A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?

• A. Keep the client's bed in the lowest position.
• B. Encourage the client to wear non-slip socks.
• C. Place a fall risk sign on the client's door.
• D. Use a gait belt when ambulating the client.

Correct answer: A

Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.

2. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

• A. Bleeding time
• B. Coagulation time
• C. Prothrombin time
• D. Partial thromboplastin time

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.

3. When is a depressed client at highest risk for attempting suicide?

• A. Immediately after admission, during one-to-one observation
• B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
• C. Following an angry outburst with family
• D. When the client is removed from the security room

Correct answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

4. A healthcare professional is assessing a client’s oculomotor nerve functions. Which of the following actions should the healthcare professional take?

• A. Check the client’s pupillary reaction to light
• B. Ask the client to read print from the Snellen chart
• C. Ask the client to identify different scents
• D. Use cotton to lightly touch the client’s cornea

Correct answer: A

Rationale: Checking the client’s pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.

5. A client is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

• A. Ensure two fingers can fit under the sleeves.
• B. Ensure the device is not too tight to impede circulation.
• C. Position the client comfortably before applying the device.
• D. Use the device continuously to prevent blood clots.

Correct answer: A

Rationale: The correct action for the nurse to take when applying a thigh-length sequential compression device to a postoperative client is to ensure that two fingers can fit under the sleeves. This action helps prevent the device from being too tight, which could impede circulation. Choice B is incorrect because the device should not be too tight, as it could lead to circulation issues. Choice C is incorrect as the client should be in a comfortable position, not necessarily supine. Choice D is incorrect as sequential compression devices are typically used continuously to prevent blood clots.

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