Nursing Elites

1. A healthcare professional is teaching a patient how to prevent falls at home. Which instruction is most appropriate?

• A. Keep your living space well-lit.
• B. Remove loose rugs and install grab bars in the bathroom.
• C. Use furniture to provide support when walking.
• D. Wear socks without shoes to prevent slipping.

Correct answer: B

Rationale: The most appropriate instruction to prevent falls at home is to remove loose rugs and install grab bars in high-risk areas like the bathroom. This helps eliminate tripping hazards and provides stability for the patient. Keeping the living space well-lit (Choice A) is important but may not directly address fall prevention. Using furniture for support (Choice C) can lead to accidents if the furniture is not stable. Wearing socks without shoes (Choice D) increases the risk of slipping rather than preventing falls.

2. A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

• A. Finger
• B. Earlobe
• C. Toe
• D. Skin fold

Correct answer: B

Rationale: When a client has edema of both hands and thickened toenails, these conditions can impede accurate readings from the finger and toe locations. The earlobe is the best alternative site for the pulse oximeter probe in this scenario. Placing the probe on the earlobe will help ensure a more accurate measurement of oxygen saturation despite the issues with the hands and toenails. Therefore, the correct answer is to apply the pulse oximeter probe to the earlobe. Choices A, C, and D are incorrect because of the potential limitations presented by the edema and thickened toenails.

3. When caring for a client's tracheostomy at home, which instruction should the nurse include in the teaching?

• A. Clean with alcohol
• B. Cover the tracheostomy when outside
• C. Replace the tube weekly
• D. Use tap water to clean

Correct answer: B

Rationale: Covering the tracheostomy when outside is crucial as it helps prevent dust and other irritants from entering the airway, reducing the risk of complications. Cleaning with alcohol (choice A) can be too harsh for the skin around the tracheostomy site. While replacing the tube weekly (choice C) is important, it is typically done by healthcare providers. Using tap water to clean (choice D) is not recommended as it may introduce contaminants to the tracheostomy site.

4. What are the nursing interventions for a patient with pneumonia?

• A. Providing fluids and rest
• B. Monitoring lung sounds and respiratory rate
• C. Encouraging coughing and deep breathing exercises
• D. Administering antibiotics and providing oxygen therapy

Correct answer: B

Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.

5. Which nursing action is essential when administering a blood transfusion?

• A. Ensure the blood is administered within 4 hours.
• B. Check the patient's vital signs every 30 minutes during the transfusion.
• C. Administer the transfusion at a slow rate for the first 15 minutes.
• D. Document the transfusion in the patient's medical record immediately after administration.

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.

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