Nursing Elites

1. The healthcare professional is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the healthcare professional to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: In obtaining a lie-sit-stand blood pressure reading, it is crucial for the healthcare professional to stay with the client while the client is standing. This action is the most important as it ensures client safety during the procedure. Recording findings, keeping the blood pressure cuff on the same arm, and monitoring pulse rate are all important tasks, but staying with the client while standing takes priority to prevent any potential falls or adverse events. By staying with the client, the healthcare professional can promptly address any signs of dizziness or instability, ensuring a safe environment for the client throughout the procedure.

2. When turning an immobile bedridden client without assistance, which action best ensures client safety?

• A. Securely grasp the client's arm and leg.
• B. Put bed rails up on the side of bed opposite from the nurse.
• C. Correctly position and use a turn sheet.
• D. Lower the head of the client's bed slowly.

Correct answer: B

Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.

3. When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

• A. On the left side of the bed facing the foot of the bed.
• B. On the right side of the bed facing the head of the bed.
• C. Perpendicular to the bed on the right side.
• D. Facing the bed on the left side of the bed.

Correct answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process. Choice B is incorrect because positioning the wheelchair on the right side facing the head of the bed would make it challenging for the client to transfer due to their right-sided hemiplegia. Choice C is incorrect as placing the wheelchair perpendicular to the bed on the right side may not provide the necessary space and angle for a safe transfer. Choice D is incorrect as facing the bed on the left side of the bed does not provide the optimal position for the client to transfer from the bed to the wheelchair effectively.

4. The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?

• A. Left brachial vein
• B. Right cephalic vein
• C. Dorsal side of the right wrist
• D. Right upper extremity

Correct answer: B

Rationale: The correct answer is B: Right cephalic vein. The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care. Choices A, C, and D are incorrect because the left brachial vein, the dorsal side of the right wrist, and the right upper extremity are not typically preferred sites for IV catheter insertion and may not provide optimal access or outcomes.

5. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

• A. Determine if the expected outcomes were realistic
• B. Obtain current client data to compare with expected outcomes
• C. Modify the nursing interventions to achieve the client’s goals
• D. Review related professional standards of care

Correct answer: A

Rationale: After reviewing the expected outcomes identified in the plan of care, the nurse's next step should be to determine if these outcomes were realistic. This assessment helps in understanding if the goals set were achievable and appropriate for the client's condition before proceeding to compare them with current client data or modifying nursing interventions. By verifying the realism of the expected outcomes, the nurse ensures a solid foundation for further evaluation and adjustment of the care plan. Option B is incorrect because obtaining current client data comes after assessing the realism of the expected outcomes. Option C is incorrect because modifying nursing interventions should be based on the assessment of the expected outcomes' realism. Option D is incorrect as reviewing professional standards of care is important but not the immediate next step after assessing the expected outcomes' realism.

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