Nursing Elites

1. Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the following is the best nursing intervention to prevent future falls?

• A. Tell Angie not to get up from bed unassisted
• B. Put the call bell within her reach
• C. Put bedside commode at the bedside to prevent Angie from getting up
• D. Put the bed in the lowest position ever

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

2. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

• A. Amount of food and fluid taken during the last meal before treatment
• B. Respiratory rate, breath sounds, and location of congestion
• C. Teaching the client's relatives to perform the procedure
• D. Doctor's order regarding position restrictions and client's tolerance for lying flat

Correct answer: B

Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.

3. In order to establish a therapeutic relationship with the client, the nurse must first have:

• A. Self awareness C. Self acceptance
• B. Self understanding D. Self motivation
• C.
• D.

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. In the hospital, when you need the medical record of a discharged patient for research you will request permission through:

• A. Doctor in charge
• B. The hospital director
• C. The nursing service
• D. Medical records section

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

5. Which meal should be removed for a client taking warfarin?

• A. Oriental cabbage salad with chicken
• B. Beef enchilada, rice, and beans
• C. Ham and cheese sandwich
• D. Macaroni salad and grapefruit slices

Correct answer: C

Rationale: The correct meal to remove for a client taking warfarin is the 'Ham and cheese sandwich.' Ham is high in vitamin K, which can interfere with the effectiveness of warfarin, a medication that works by decreasing the clotting ability of the blood. Vitamin K can counteract the effects of warfarin by promoting blood clotting. Choices A, B, and D do not contain high amounts of vitamin K and are therefore safer options for individuals taking warfarin.

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