Nursing Elites

1. During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?

• A. Assign an unlicensed assistive personnel to transport the client via a wheelchair.
• B. Remind the client to walk carefully down the stairs until reaching a lower floor.
• C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
• D. Open the closest fire doors to facilitate the evacuation of ambulatory clients.

Correct answer: B

Rationale: During a fire evacuation, it is crucial for ambulatory clients to be reminded to walk carefully down the stairs. This helps ensure the safety of the client by preventing falls or injuries during the evacuation process. Directing the client to proceed cautiously down the stairs until reaching a lower floor provides necessary guidance to promote a safe evacuation process. Choice A is incorrect because assigning unlicensed assistive personnel to transport the client via a wheelchair may delay the evacuation process and increase the risk of injury. Choice C is incorrect as it distracts the ambulatory client from evacuating safely by involving them in assisting another client. Choice D is incorrect as opening fire doors may not be the most appropriate action at that moment; prioritizing safe evacuation procedures for ambulatory clients is essential.

2. A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?

• A. Increase fluid intake to 3 liters per day.
• B. Limit sodium intake to 2 grams per day.
• C. Avoid foods high in potassium.
• D. Increase protein intake to promote healing.

Correct answer: B

Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Excessive sodium can lead to fluid retention, worsening heart failure symptoms. Increasing fluid intake (A) can further exacerbate fluid overload in heart failure patients. Avoiding foods high in potassium (C) is not necessary unless the client has hyperkalemia; in heart failure, potassium restriction is not a primary dietary concern. Increasing protein intake (D) is not the priority for heart failure management; focusing on sodium restriction is more beneficial.

3. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

• A. Check the bath water temperature.
• B. Shut the bathroom door.
• C. Ensure that the client has voided.
• D. Provide extra towels.

Correct answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

4. What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?

• A. Elevate the head of the bed to 45 degrees.
• B. Monitor the client's respiratory rate.
• C. Administer an antihypertensive medication.
• D. Assess the client's blood glucose level.

Correct answer: A

Rationale: In a client with autonomic dysreflexia, the most critical action is to elevate the head of the bed to 45 degrees (A). This positioning helps reduce blood pressure, which is essential in managing autonomic dysreflexia. Monitoring the client's respiratory rate (B) is important for overall assessment but not the priority in this situation. Administering an antihypertensive medication (C) without addressing the positioning issue first can lead to further complications. Assessing the client's blood glucose level (D) is not directly related to autonomic dysreflexia and is not the initial priority in this scenario.

5. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

• A. Witness the client's signature on the permit.
• B. Answer the client's questions about the surgery.
• C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
• D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Correct answer: C

Rationale: The nurse should inform the surgeon promptly that the operative permit is not signed and the client has questions about the surgery. It is crucial for the surgeon to be aware of these issues as it is their responsibility to explain the procedure to the client and ensure that the necessary consent is obtained before proceeding with the surgery. Answering the client's questions directly (choice B) may not be appropriate as the surgeon is the one responsible for providing detailed information about the procedure. Witnessing the client's signature (choice A) is premature since the permit is not signed. Reassuring the client (choice D) is not the most appropriate action at this point; the priority is to involve the surgeon in addressing the unsigned permit and the client's questions.

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