Nursing Elites

1. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

2. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first?

• A. Assessment
• B. History of present illness
• C. Plan of care
• D. Admission date and time

Correct answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

3. A client is being taught how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?

• A. I will straighten my ear canal by pulling my ear down and back.
• B. I will gently apply pressure with my finger to the front part of my ear after putting in the drops.
• C. I will insert the nozzle of the ear drop bottle snugly into my ear before squeezing the drops in.
• D. After the drops are in, I will place a cotton ball all the way into my ear canal.

Correct answer: B

Rationale: The correct answer is B. Gently applying pressure to the front part of the ear after administering drops helps with absorption. Pulling the ear down and back is a correct technique for adults. Snugly inserting the nozzle of the ear drop bottle or placing a cotton ball all the way into the ear canal is unnecessary and can potentially cause harm or discomfort. Therefore, choices A, C, and D are incorrect.

4. A healthcare professional is caring for a client who has a prescription for morphine 5mg IM but accidentally administers the entire 10mg from the single-dose vial. Which of the following actions should the healthcare professional take first?

• A. Complete an incident report
• B. Measure the client’s respiratory rate
• C. Report the incident to the pharmacy
• D. Notify the client's provider

Correct answer: B

Rationale: Assessing the client's respiratory rate is the priority in this situation as overdosing on morphine can lead to respiratory depression, making it crucial to monitor the client's breathing. Completing an incident report (choice A) is important but should not be the first action. Reporting the incident to the pharmacy (choice C) and notifying the client's provider (choice D) are necessary steps but assessing the client's respiratory status takes precedence to ensure immediate safety and intervention.

5. In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:

• A. Be at an increased susceptibility for infection
• B. Have a wound that heals more slowly
• C. Experience more pain during the healing process
• D. Require more frequent dressing changes

Correct answer: A

Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.

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