Nursing Elites

1. The nurse is assisting the recreational director of a long-term care facility in planning outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

• A. An open-air concert
• B. A tea party in the courtyard
• C. A team ring-toss competition
• D. A picnic in the park

Correct answer: B

Rationale: A tea party in the courtyard provides a social and physical activity suitable for wheelchair-bound older residents who are mentally alert. It offers an opportunity for social interaction, enjoyment of the outdoors, and participation in a physical activity without the need for extensive mobility. An open-air concert may not provide the same level of social interaction or physical engagement as a tea party. A team ring-toss competition may be physically challenging for wheelchair-bound residents. A picnic in the park could present challenges related to accessibility and might not foster the same level of social interaction as a tea party in a more contained courtyard setting.

2. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?

• A. Apply a pulse oximeter
• B. Measure blood pressure
• C. Notify the charge nurse
• D. Observe pressure areas

Correct answer: C

Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.

3. The nurse is caring for an elderly female client who tells the nurse, 'When I sneeze, I wet my pants.' After discussing the client's complaint with the charge nurse, the nurse plans to reinforce teaching about the importance of Kegel exercises. What muscles are involved in these exercises?

• A. Pectoral muscles
• B. Buttock muscles
• C. Abdominal muscles
• D. Pelvic floor muscles

Correct answer: D

Rationale: Kegel exercises involve the pelvic floor muscles. These muscles help strengthen the muscles controlling urination, potentially reducing symptoms of urinary incontinence. Pectoral muscles (Choice A), responsible for movement of the shoulders and arms, are not involved in Kegel exercises. Buttock muscles (Choice B) are primarily responsible for hip movement and stability, not related to Kegel exercises. Abdominal muscles (Choice C) support the core and trunk but are not the focus of Kegel exercises.

4. The client diagnosed with HIV is taught by the nurse that the condition is transmitted through

• A. the infection passed from a mother to her baby
• B. Tears
• C. human bites
• D. insect bites

Correct answer: A

Rationale: HIV can be transmitted from a mother to her baby during childbirth or breastfeeding, making choice A the correct answer. Tears, human bites, and insect bites are not common modes of HIV transmission. While human bites can potentially transmit the virus, it is less common compared to mother-to-child transmission.

5. A client who is post-operative from a spinal fusion surgery reports a sudden onset of severe headache when sitting up. What is the nurse’s priority action?

• A. Administer pain medication.
• B. Lay the client flat and notify the healthcare provider.
• C. Encourage the client to drink more fluids.
• D. Assess the client’s surgical site for drainage.

Correct answer: B

Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.

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