Nursing Elites

1. An older postoperative client has the nursing diagnosis 'impaired mobility related to fear of falling.' Which desired outcome best directs the PN's actions for the client?

• A. The client will ambulate with assistance every 4 hours
• B. The physical therapist will instruct the client in the use of a walker
• C. The client will use self-affirmation statements to decrease fear
• D. The PN will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: The correct answer is C. Using self-affirmation statements helps the client reduce fear and regain confidence in mobility, which is essential for improving impaired mobility. Choice A focuses more on the frequency of ambulation rather than addressing the fear of falling. Choice B involves the physical therapist and the use of a walker, which may not directly address the client's fear. Choice D is a safety measure but does not specifically target the client's fear of falling.

2. A client who had a right total shoulder replacement is being prepared for discharge. What should the nurse emphasize to the client to prevent complications?

• A. Avoid lifting objects with the right arm until cleared by the surgeon.
• B. Perform shoulder exercises to regain strength.
• C. Use a sling at all times, even during sleep.
• D. Apply heat to the shoulder to reduce stiffness.

Correct answer: A

Rationale: The correct answer is to avoid lifting objects with the right arm until cleared by the surgeon. After a total shoulder replacement, it is essential to protect the new joint to prevent dislocation or injury. Lifting heavy objects prematurely can lead to complications. While performing shoulder exercises is important for strength, they should be done as per the healthcare provider's instructions to avoid strain on the new joint. Using a sling at all times, as in choice C, is not necessary once the client has regained enough strength and mobility. Applying heat, as in choice D, may not be recommended post-surgery; cold therapy is often preferred to reduce swelling and pain.

3. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

• A. Using a sterile technique
• B. Ensuring correct placement of the CVC
• C. Flushing the CVC with saline after administration
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

4. An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan?

• A. Plan to have the same nursing staff provide care for the client whenever possible
• B. Describe the activities available to residents and encourage him to choose the ones he prefers
• C. Encourage the client to remain on the unit for three weeks until he is oriented to his new surroundings
• D. Introduce the client to the nursing staff and other residents as soon as possible

Correct answer: A

Rationale: The correct intervention for a client with Alzheimer's disease in an extended care facility is to plan to have the same nursing staff provide care whenever possible. Consistency in caregivers helps reduce confusion and anxiety in clients with Alzheimer’s disease, promoting a stable and supportive environment for the client. Choice B is incorrect as it focuses on activities rather than the consistency of caregivers. Choice C is incorrect as it suggests isolating the client, which can lead to increased confusion and distress. Choice D is incorrect as introducing the client to new people immediately can be overwhelming and may exacerbate their symptoms.

5. The home health PN suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the PN to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: The most important action for the PN to take in this situation is to report the findings to the supervisor for referral to adult protective services. Suspected elder abuse must be reported promptly to ensure the safety and protection of the client. Documenting the lacerations in the client's record is important but not as critical as reporting the suspected abuse. Asking the daughter who is the potential abuser may not yield accurate information and could compromise the safety of the client. Applying dressings to the wounds is a lower priority compared to addressing the suspected elder abuse.

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