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. A healthcare provider is receiving a prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the healthcare provider clarify?

• A. Dietitian consult
• B. Speech therapy referral
• C. Oral suction at the bedside
• D. Clear liquids

Correct answer: D

Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at high risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids. Therefore, the healthcare provider should clarify the prescription for clear liquids and consider recommending thickened liquids instead to reduce the risk of aspiration. Choice A, 'Dietitian consult,' is essential to ensure the client receives appropriate nutrition tailored to their condition. Choice B, 'Speech therapy referral,' is crucial for dysphagia management and rehabilitation. Choice C, 'Oral suction at the bedside,' is a standard intervention to maintain airway patency and is not contraindicated in clients with dysphagia.

3. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?

• A. pH below 7.3
• B. Potassium of 5.0
• C. HCT of 60
• D. PaO2 of 79%

Correct answer: C

Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.

4. When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, the next action by the nurse should be to

• A. Discuss the feeling of reluctance with an objective peer or supervisor
• B. Limit contacts with the client to avoid reinforcement of manipulative behavior
• C. Confront the client about the negative effects of behaviors on other clients and staff
• D. Develop a behavior modification plan that will promote more functional behavior

Correct answer: A

Rationale: When a nurse experiences reluctance to interact with a manipulative client, it is essential to address these feelings constructively. Discussing the feeling of reluctance with an objective peer or supervisor allows the nurse to gain perspective, reflect on the situation, and develop appropriate strategies for patient care. This action promotes self-awareness, professional growth, and ensures that patient care is not compromised. Option B is incorrect because avoiding the client may not address the underlying issues and can impact the therapeutic relationship. Option C is inappropriate as confronting the client may escalate the situation and hinder effective communication. Option D is not the immediate action needed in this scenario, as it focuses on behavior modification rather than addressing the nurse's feelings of reluctance.

5. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

• A. Perform deep palpation at the end of the admission assessment
• B. Auscultate the client’s abdomen before palpation
• C. Begin palpation of the abdomen at the site of pain
• D. Assess the client’s bowel sounds using the bell of the stethoscope

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

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