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. A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include?

• A. “Keep a nightlight on in the bathroom”
• B. “Set room temperature to 68 degrees Fahrenheit”
• C. “Place throw rugs over electrical cords”
• D. “Use chairs without armrests”

Correct answer: A

Rationale: The correct answer is A: 'Keep a nightlight on in the bathroom.' This safety measure is crucial for older adults to prevent falls by enhancing visibility during nighttime bathroom visits. Choice B is incorrect because setting the room temperature to 68 degrees Fahrenheit may not be universally suitable for all older adults, as individual preferences vary. Choice C is incorrect as placing throw rugs over electrical cords poses a tripping hazard rather than enhancing safety. Choice D is incorrect as using chairs without armrests may not provide adequate support and stability for older adults, increasing the risk of falls.

3. A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

• A. 8 mL/hr
• B. 10 mL/hr
• C. 12 mL/hr
• D. 15 mL/hr

Correct answer: A

Rationale: To calculate the infusion rate, use the formula: (Desired units/hr / Total units) × Volume. In this case, it would be (800 units/hr / 25,000 units) × 250 mL = 8 mL/hr. Therefore, the nurse should set the infusion pump at 8 mL/hr. Choice B, 10 mL/hr, is incorrect because it does not match the calculated rate. Choices C and D, 12 mL/hr and 15 mL/hr respectively, are also incorrect as they do not align with the correct calculation based on the provided data.

4. Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?

• A. Assess the client's mobility
• B. Evaluate the pedal pulses
• C. Monitor skin temperature
• D. Check for swelling

Correct answer: B

Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.

5. The caregiver is teaching parents about the diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include

• A. Formula or breast milk
• B. Broth and tea
• C. Rice cereal and apple juice
• D. Gelatin and ginger ale

Correct answer: A

Rationale: The correct answer is A: Formula or breast milk. In infants with gastroenteritis and mild dehydration, it is essential to continue feeding them with formula or breast milk along with oral rehydration fluids to provide adequate nutrition and maintain hydration. Option B, broth and tea, may not provide the necessary nutrients and electrolytes needed for the infant's recovery. Option C, rice cereal and apple juice, can be harsh on the digestive system and may exacerbate diarrhea. Option D, gelatin and ginger ale, do not provide the necessary nutrients and can worsen the condition due to the high sugar content in ginger ale.

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