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. How should a healthcare provider manage a patient with deep vein thrombosis (DVT)?

• A. Monitoring for signs of pulmonary embolism
• B. Applying compression stockings
• C. Administering anticoagulants as prescribed
• D. Encouraging leg elevation to reduce swelling

Correct answer: A

Rationale: Corrected Rationale: Monitoring for signs of pulmonary embolism is crucial in patients with deep vein thrombosis (DVT) as it can be a life-threatening complication. While administering anticoagulants as prescribed is important for preventing clot progression, the immediate concern is detecting potential pulmonary embolism. Applying compression stockings and encouraging leg elevation are beneficial measures for managing DVT symptoms but are not as critical as monitoring for pulmonary embolism.

3. A client is about to undergo surgery and is unsure about the procedure despite signing the consent. What should the nurse do?

• A. Reassure the client and proceed with the surgery.
• B. Stop the surgery and consult with the surgeon.
• C. Proceed with the surgery but document the client's concerns.
• D. Postpone the surgery until further clarification is provided.

Correct answer: B

Rationale: When a client expresses doubts about a procedure after signing the consent form, it is crucial to stop the surgery and consult with the surgeon. This is important to ensure that the client's concerns are addressed, and there is a clear understanding of the procedure. Reassuring the client and proceeding with the surgery (choice A) may violate the client's autonomy and right to informed consent. Proceeding with the surgery but documenting the concerns (choice C) is not sufficient as the client's doubts should be resolved before proceeding. Postponing the surgery until further clarification is provided (choice D) may be necessary, but the immediate step should be to consult with the surgeon to address the client's concerns.

4. A patient is receiving an opioid analgesic for pain management. What is the most important assessment for the nurse to perform?

• A. Monitor the patient's blood pressure.
• B. Assess the patient's respiratory rate.
• C. Monitor the patient's oxygen saturation.
• D. Assess the patient's heart rate.

Correct answer: B

Rationale: The correct answer is to assess the patient's respiratory rate. When a patient is receiving opioids, it is crucial to monitor their respiratory rate as opioids can depress the respiratory system, leading to respiratory depression and potential respiratory failure. Monitoring blood pressure, oxygen saturation, and heart rate are important assessments as well, but the priority lies in assessing respiratory rate due to the risk of respiratory depression associated with opioid use.

5. What is the most appropriate action for a healthcare provider to take when a patient refuses a prescribed medication?

• A. Document the refusal and notify the healthcare provider.
• B. Administer the medication at a later time.
• C. Explain the importance of the medication and its effects.
• D. Respect the patient's right to refuse the medication.

Correct answer: D

Rationale: The correct answer is to respect the patient's right to refuse the medication. It is crucial to uphold the patient's autonomy and decision-making capacity when it comes to their treatment. Administering the medication later without the patient's consent (Choice B) disregards their autonomy and can lead to ethical issues. Documenting the refusal and notifying the healthcare provider (Choice A) is important for legal and continuity of care purposes but should come after respecting the patient's decision. While explaining the importance of the medication (Choice C) is valuable for promoting understanding and compliance, the immediate concern should be respecting the patient's refusal.

Similar Questions