Nursing Elites

1. When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?

• A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.

2. Which of the following medications would NOT be an appropriate prn medication for use during an episode of aggression or violence for the patient with a psychiatric diagnosis?

• A. Olanzapine
• B. Meperidine
• C. Ziprasidone
• D. Haloperidol

Correct answer: B

Rationale: Meperidine is an opioid used to treat pain and is not suitable for managing aggressive or violent behavior in patients with psychiatric diagnoses. Olanzapine, ziprasidone, and haloperidol are appropriate choices for managing aggression or violence. Olanzapine and ziprasidone are second-generation antipsychotic medications, while haloperidol is a traditional antipsychotic. These medications have demonstrated effectiveness in managing aggressive behavior, with or without the adjunctive use of a benzodiazepine. Meperidine's primary indication is for pain relief, making it unsuitable for managing psychiatric-related aggression or violence.

3. Which response would the nurse provide to a client in labor at 32 weeks' gestation who tells the nurse that she and her husband are very concerned because the baby will be born 2 months early?

• A. ''You should be concerned. I feel for you.''
• B. 'If you're concerned, let's talk about it.''
• C. ''Try not to worry about it; just concentrate on your labor.''
• D. 'Don't worry; the care of preterm babies has greatly improved.''

Correct answer: B

Rationale: The correct answer is B: ''If you're concerned, let's talk about it.'' Offering to talk with the client encourages her to verbalize concerns, serving as an outlet for tension. The nurse's first step should be to listen to the client's concerns and emotions before providing more specific information. Choice A is incorrect as telling the client she should be concerned reinforces fears and conveys sympathy rather than empathy. Choice C is incorrect because telling the client not to worry and just concentrate on labor denies the client's feelings and cuts off communication. Choice D is incorrect as telling the client not to worry because care has improved denies the client's feelings and provides false reassurance.

4. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

5. On her first visit to the neonatal intensive care unit to see her preterm newborn, the mother's only comment to the nurse is, 'My baby looks so fragile. Do you think my child will make it?' Which is the most appropriate response by the nurse?

• A. "Many infants born as small as yours have done just fine."
• B. "The staff is confident in your child's prognosis because preterm babies do look like this at first."
• C. "It's understandable that your baby looks fragile to you. What have you learned about the condition?"
• D. "Your baby is not as fragile as it appears. Do you find it so frightening that you can't touch your child?"

Correct answer: C

Rationale: The nurse's response should aim to convey acceptance and encourage the mother to express her concerns. By saying, "It's understandable that your baby looks fragile to you. What have you learned about the condition?", the nurse acknowledges the mother's feelings and prompts her to share her understanding, fostering further communication and addressing any misconceptions. Choices A and B dismiss the mother's concerns by making general statements and do not encourage dialogue. Choice D implies judgment and may deter the mother from opening up about her fears.

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