Nursing Elites

1. A healthcare professional is preparing to transfer a client from a chair to a bed. The client can bear partial weight and has upper body strength. Which device should the healthcare professional use?

• A. Hydraulic lift
• B. Stand-assist lift
• C. Wheelchair
• D. Mechanical lift

Correct answer: B

Rationale: A stand-assist lift is the appropriate device for transferring a client who can bear partial weight and has upper body strength. This device provides support for the client to stand up and be transferred safely. A hydraulic lift is more suitable for transferring clients who cannot bear weight. A wheelchair is used for mobility but not for transferring between a chair and a bed. A mechanical lift is typically used for transferring clients who are unable to bear weight or have limited mobility.

2. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?

• A. Weight loss
• B. Decreased blood pressure
• C. Edema
• D. Increased urine output

Correct answer: C

Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

4. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

• A. Providing a high-protein snack
• B. Assisting the child to reposition
• C. Placing weights on the child’s bed
• D. Massaging pressure points

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

5. A client is receiving ferrous sulfate. Which of the following should be monitored?

• A. Serum potassium levels
• B. Hemoglobin levels
• C. Liver function tests
• D. Blood glucose levels

Correct answer: B

Rationale: The correct answer is B: Hemoglobin levels. Ferrous sulfate is used to treat iron deficiency anemia by increasing the body's iron stores. Monitoring hemoglobin levels is crucial as it reflects the effectiveness of the treatment in improving the client's anemia. Serum potassium levels (Choice A) are typically not directly affected by ferrous sulfate. Liver function tests (Choice C) and blood glucose levels (Choice D) are not routinely monitored when a client is receiving ferrous sulfate unless there are specific indications or pre-existing conditions that warrant such monitoring.

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