Nursing Elites

1. A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?

• A. Assess the client for orthostatic hypotension
• B. Obtain a gait belt
• C. Ensure the client has proper footwear
• D. Ask the client to perform range-of-motion exercises

Correct answer: A

Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.

2. The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?

• A. I will stop taking the medication if I experience dizziness.
• B. I will monitor my blood pressure regularly.
• C. I will avoid drinking alcohol while taking this medication.
• D. I will rise slowly from a sitting to a standing position.

Correct answer: A

Rationale: The correct answer is A. Stopping antihypertensive medication abruptly can lead to rebound hypertension, which can be dangerous. Clients should never discontinue their medication without consulting their healthcare provider first. Choice B is correct because monitoring blood pressure is essential when taking antihypertensive medication to ensure it stays within the target range. Choice C is correct as alcohol can potentiate the hypotensive effects of antihypertensive medications. Choice D is correct as orthostatic hypotension can occur, so rising slowly helps prevent dizziness and falls. Therefore, choice A is the statement that indicates a need for further teaching.

3. A client is being taught about medications at discharge. Which statement should the nurse identify as an indication that the client understands the instructions?

• A. I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal.
• B. If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding.
• C. I can crush the enteric-coated pill if needed.
• D. I will eat two crackers with the pain pills.

Correct answer: B

Rationale: The correct answer is B. Adding liquid medication to pudding can help with swallowing difficulties, demonstrating understanding of the instructions. Options A and C are incorrect as altering time-release capsules and enteric-coated pills is not recommended in medication administration. Option A is incorrect as time-release capsules should not be opened and sprinkled on food, affecting their efficacy. Option C is incorrect as crushing enteric-coated pills can affect their absorption. Option D is unrelated to medication administration and does not demonstrate understanding of the instructions.

4. When assessing the skin of an immobilized patient, what should the nurse do?

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

Correct answer: C

Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.

5. A healthcare professional is collecting a urine specimen for a client to test via urine dipstick to determine the urine's specific gravity. The healthcare professional knows the result will indicate the amount of:

• A. Solutes in the urine
• B. Bacteria in the urine
• C. pH level of the urine
• D. Glucose in the urine

Correct answer: A

Rationale: Specific gravity measures the concentration of solutes in the urine, reflecting the kidney's ability to concentrate or dilute urine. Choice B, bacteria in the urine, is incorrect because specific gravity does not measure bacterial presence. Choice C, pH level of the urine, is incorrect as it refers to the acidity or alkalinity of the urine, not its specific gravity. Choice D, glucose in the urine, is incorrect as specific gravity does not directly measure glucose levels in urine.

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