Nursing Elites

1. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

• A. Use a mechanical lift to reposition the client every 2 hours
• B. Elevate the client's head of the bed to 45 degrees
• C. Postpone daily bed bath
• D. Caregiver independently slides the client up in the bed

Correct answer: A

Rationale:

2. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer a protein-rich diet
• C. Offer the client a bedpan for toileting
• D. Turn the client every 4 hours

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

3. The mother of a newborn baby is concerned that the baby will develop illnesses from being around people from outside of their family. What is the nurse's best response?

• A. "You should never go around people after your baby is born,"?
• B. "Why do you think that is a bad idea?"?
• C. "Tell me more about that."?
• D. "I did that, and my kids turned out just fine."?

Correct answer: C

Rationale:

4. A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

• A. Traumatic injury
• B. Pressure injury
• C. Friction injury
• D. Shearing injury

Correct answer: D

Rationale:

5. What is the nurse's priority action for a client with compromised immunity?

• A. Wash hands before entering the client's room
• B. Take the client's vital signs every 4 hours
• C. Determine whether it is temporary or permanent
• D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

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