Nursing Elites

1. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

• A. Bag bath
• B. Sponge bath
• C. Partial bed bath
• D. Complete bed bath

Correct answer: C

Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.

2. While auscultating the anterior chest of a newly admitted patient, what would the nurse expect to hear?

• A. Normal breathing sounds
• B. Wheezing
• C. Crackles
• D. Stridor

Correct answer: A

Rationale: When auscultating the chest, normal breathing sounds are expected in a healthy individual. Wheezing is a high-pitched whistling sound that indicates narrowed airways and is often heard in conditions like asthma. Crackles are fine, crackling sounds heard on inspiration or expiration and are associated with conditions like pneumonia or heart failure. Stridor is a high-pitched, harsh sound heard during inspiration due to upper airway obstruction. Therefore, choices B, C, and D indicate abnormal respiratory findings, while choice A signifies normal breathing sounds.

3. A client who has a new prescription for warfarin (Coumadin) is receiving discharge teaching from a nurse. Which of the following statements indicates that the client understands the teaching?

• A. I will take my warfarin at the same time every day.
• B. I should use a soft-bristled toothbrush while taking this medication.
• C. I should take my warfarin at bedtime.
• D. I should avoid eating foods high in vitamin K while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Taking warfarin at the same time every day is essential to maintain a consistent blood level of the medication. This statement indicates that the client understands the teaching about the importance of consistency in medication timing. Choice B, regarding using a soft-bristled toothbrush, is not directly related to warfarin therapy and does not assess the client's understanding of warfarin administration. Choice C suggesting taking warfarin at bedtime is incorrect; it is generally recommended to take warfarin at the same time each day to avoid variations in drug levels. Choice D about avoiding foods high in vitamin K is relevant as vitamin K can interfere with warfarin's anticoagulant effects. However, it is not the best indicator of understanding the teaching on medication timing, which is crucial for warfarin efficacy.

4. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?

• A. Wearing gloves during the procedure
• B. Using a sterile solution
• C. Irrigating from the inner to the outer canthus
• D. Positioning the client's head properly

Correct answer: A

Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.

5. A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take?

• A. Ensure that the width of the BP cuff is appropriate for the client's arm circumference.
• B. Reposition the client supine and recheck their BP.
• C. Recheck the client's BP and measure their other arm for comparison.
• D. Request that another nurse check the client's BP in 30 minutes.

Correct answer: C

Rationale: When a nurse obtains a blood pressure reading that is elevated, the appropriate action is to recheck the client's BP and measure the other arm for comparison. This step helps ensure accuracy by ruling out errors like improper cuff size, positioning, or equipment malfunction. Repositioning the client supine is not necessary unless the client shows signs of distress or symptoms. Ensuring the appropriate cuff width is important for accurate readings but does not address the immediate need to confirm the current BP. Requesting another nurse to check the BP in 30 minutes delays immediate action and does not address the need for verification and comparison of the current reading.

Similar Questions