Nursing Elites

1. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

• A. Place the chair at a right angle to the bed on the client's left side before moving.
• B. Assist the client to a standing position, then place the right hand on the armrest.
• C. Have the client place the left foot next to the chair and pivot to the left before sitting.
• D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Correct answer: D

Rationale: The correct transfer procedure for an elderly client with left-sided weakness involves moving the chair parallel to the right side of the bed and standing the client on the right foot. Using the stronger side, the right side, for weight-bearing during the transfer is the safest approach to prevent falls or injuries. Placing the chair at a right angle to the bed on the client's left side before moving can lead to poor body mechanics and increase the risk of accidents. Assisting the client to a standing position and having the client pivot to the left are not recommended for a client with left-sided weakness as it can compromise safety and stability during the transfer.

2. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?

• A. Clamp the catheter and recheck it in 60 minutes.
• B. Pull the catheter back 3 inches and redirect it upward.
• C. Leave the catheter in place and reattempt with another catheter.
• D. Notify the healthcare provider of a possible obstruction.

Correct answer: C

Rationale: In this scenario, if no urine is seen in the tubing after inserting the catheter, it is likely that the catheter is in the vagina rather than the bladder. Leaving the first catheter in place will help locate the meatus more easily when attempting the second catheterization. This approach ensures correct placement of the catheter in the bladder and minimizes the risk of causing unnecessary discomfort or trauma to the patient.

3. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

• A. Check for a blood return.
• B. Reposition the client's arm.
• C. Remove the IV site dressing.
• D. Flush the lock with saline.

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

4. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

• A. Acknowledge that she is supporting the arm correctly.
• B. Encourage her to keep the joint uncovered to maintain warmth.
• C. Reinforce the need to grip directly under the joint for better support.
• D. Instruct her to grip directly over the joint for better motion.

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

5. Mr. Landon is scheduled to undergo a tracheostomy. Which nursing action is essential during tracheal suctioning?

• A. Using a water-soluble lubricant.
• B. Administering 100% oxygen before and after suctioning.
• C. Ensuring that the suction catheter is open during insertion.
• D. Assisting the client to assume a semi-Fowler's position during suctioning.

Correct answer: B

Rationale: Administering 100% oxygen before and after suctioning is crucial to prevent hypoxia, which can occur during tracheal suctioning. Hypoxia can lead to serious complications, making the provision of oxygen essential in maintaining adequate oxygenation levels for the patient undergoing tracheal suctioning. Choice A is incorrect because using a water-soluble lubricant is not directly related to the essential nursing action during tracheal suctioning. Choice C is incorrect as ensuring that the suction catheter is open during insertion is a basic requirement and not the essential action for oxygenation. Choice D is incorrect because assisting the client to assume a semi-Fowler's position is beneficial for comfort and airway alignment but is not as crucial as administering oxygen to prevent hypoxia.

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