Nursing Elites

1. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

• A. Elevate the head of the bed no more than 45 degrees
• B. Apply cornstarch to keep sensitive skin areas dry
• C. Massage the skin over the client's bony prominences
• D. Use a transfer device to lift the client up in bed

Correct answer: D

Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.

2. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

• A. CT scan
• B. MRI
• C. X-ray
• D. Ultrasound

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

3. A nurse manager assigns a nursing assistant a task outside of their role. What should the nursing assistant do?

• A. Follow the manager's directive
• B. Report the task to the charge nurse
• C. Refuse to perform the task
• D. Perform the task and document later

Correct answer: B

Rationale: If a nurse manager assigns a nursing assistant a task that is outside of their role, the nursing assistant should report the task to the charge nurse. This is important because the charge nurse can provide guidance on whether the task is appropriate for the nursing assistant to perform. Choice A is incorrect because blindly following a directive that is outside of the nursing assistant's scope could lead to negative consequences. Choice C might not be the best course of action initially, as it's important to seek clarification first. Choice D is also not the best option because performing a task outside of one's role without proper authorization can pose risks to both the patient and the nursing assistant.

4. What is the most appropriate method for assessing a patient's pain level?

• A. Observe the patient's facial expressions.
• B. Use a standardized pain scale, such as 0-10.
• C. Ask the patient to rate their pain based on their mood.
• D. Ask the patient's family members to assess the pain.

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

5. Which intervention is essential when caring for a patient with a nasogastric (NG) tube?

• A. Suction the NG tube every 4 hours.
• B. Check the placement of the NG tube before each feeding.
• C. Flush the NG tube with water before and after each medication administration.
• D. Remove the NG tube once the patient feels comfortable.

Correct answer: B

Rationale: Checking the placement of the NG tube before each feeding is crucial to ensure it is correctly positioned and safe to use. Option A is incorrect as routine suctioning can lead to complications and should only be done as needed. Option C is not necessary unless there are specific instructions for flushing. Option D is incorrect as the NG tube should only be removed by healthcare professionals based on medical criteria, not solely based on the patient's comfort.

Similar Questions