Nursing Elites

1. While caring for a client who, while sitting in a chair, starts to experience a seizure, what action should the nurse take?

• A. Lower the client to the floor and place a pad under the client's head.
• B. Hold the client's head still to prevent injury.
• C. Restrain the client to prevent movement.
• D. Place the client in a supine position.

Correct answer: A

Rationale: During a seizure, the priority is to lower the client to the floor to prevent injury and ensure their safety. Placing a pad under the client's head helps protect the head from injury. Choice B, holding the client's head still, is incorrect as it can lead to harm; it's essential to allow movement during a seizure to prevent neck injury. Choice C, restraining the client, is dangerous and can cause harm by restricting movement. Choice D, placing the client in a supine position, is also not recommended during a seizure as it does not provide adequate protection for the client.

2. A client reports abdominal pain. An assessment by the nurse reveals a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Overdue menses

Correct answer: A

Rationale: The nurse's priority should be the client's temperature. A high temperature of 39.2 degrees C (102 degrees F) indicates a potential infection or inflammation that requires immediate attention. While heart rate and abdominal tenderness are important assessments, the temperature takes precedence as it signals a more urgent issue. Overdue menses, although significant, are not the priority in this scenario when compared to the possibility of an acute infection or inflammatory process.

3. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?

• A. Calf swelling
• B. Elevated blood pressure
• C. Decreased urine output
• D. Generalized rash

Correct answer: A

Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.

4. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

• A. Wear cotton clothing to avoid static electricity.
• B. Avoid using any electrical appliances.
• C. Keep the oxygen tank away from heat sources.
• D. Use only a specific type of nasal cannula.

Correct answer: A

Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.

5. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

• A. Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae
• B. Use a mechanical lift
• C. Twist at the waist while holding the client
• D. Ask for assistance from another staff member

Correct answer: A

Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client’s hands on the nurse’s shoulders and the nurse’s hands under the client’s axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.

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