Nursing Elites

1. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

• A. Loud volume of the television set
• B. Wall-to-wall carpet in the living room
• C. Low chairs without armrests
• D. Use of indirect lighting

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

2. A nurse sees another nurse administering medication without using alcohol swabs. What is the first action the nurse should take?

• A. Ignore the situation to maintain a good working relationship.
• B. Report the behavior to the nurse manager.
• C. Ask the colleague to be more careful next time.
• D. Report the issue after speaking to other colleagues.

Correct answer: B

Rationale: The correct action for the nurse to take when witnessing unsafe medication administration practices, such as not using alcohol swabs, is to report the behavior to the nurse manager immediately. Patient safety is the top priority, and any actions that compromise it must be addressed promptly. Ignoring the situation (Choice A) is not appropriate as it puts patients at risk. Asking the colleague to be more careful (Choice C) may not be effective in ensuring immediate correction of the unsafe practice. Reporting the issue after speaking to other colleagues (Choice D) delays necessary action and may compromise patient safety further.

3. A nurse is assessing the skin of an immobilized patient. What will the nurse do?

• A. Use a standardized tool such as the Braden Scale.
• B. Limit the amount of fluid intake.
• C. Have special times for inspection so as not to interrupt routine care.
• D. Assess the skin every 4 hours.

Correct answer: A

Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.

4. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?

• A. Encourage the patient to take deep breaths.
• B. Assist the patient to sit down slowly.
• C. Instruct the patient to use a walker for support.
• D. Teach the patient how to change positions safely.

Correct answer: B

Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.

5. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

• A. Self-report of pain
• B. Nonverbal behavior
• C. Severity of the condition
• D. Vital signs

Correct answer: A

Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.

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