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. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?

• A. Aspirating gastric contents to assure a pH value of 4 or less.
• B. Hearing air pass in the stomach after injecting air into the tubing.
• C. Examining a chest x-ray obtained after the tubing was inserted.
• D. Checking the remaining length of tubing to ensure that the correct length was inserted.

Correct answer: C

Rationale: The most accurate method to confirm the proper placement of a nasogastric tube is by examining a chest x-ray obtained after the tubing was inserted. This visual assessment allows healthcare providers to directly visualize the position of the tube in relation to anatomical landmarks, ensuring it is correctly placed in the stomach. Aspirating gastric contents or hearing air pass may provide some information but are not as definitive as a chest x-ray for confirming placement. Checking the remaining length of tubing is not a reliable method for determining proper placement as it does not indicate where the tip of the tube lies within the body.

3. The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.

4. A client with a suspected kidney infection is admitted to the hospital for observation. Which action should the nurse implement to assess the client’s kidney function?

• A. Monitor the client’s urine output
• B. Check for abdominal tenderness
• C. Evaluate the client’s fluid intake
• D. Inspect the client’s skin for edema

Correct answer: A

Rationale: Monitoring urine output is the most direct way to assess kidney function as it provides crucial information about the kidneys’ ability to filter waste and produce urine. Changes in urine output can indicate potential issues with kidney function, such as decreased filtration or impaired excretion of waste products.

5. What action should be taken when adding sterile liquids to a sterile field?

• A. Use an expired sterile liquid if the bottle is sealed and unopened.
• B. Consider the sterile field contaminated if it becomes wet during the procedure.
• C. Remove the container cap and place it with the inside facing up on the sterile field.
• D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

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