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. You are assigned to teach a student how to suction an adult patient with a tracheostomy. Which of the following actions by the student would be incorrect?

• A. Pre-oxygenating the patient with a Resuscibag at 100% O2 several times before suctioning.
• B. Maintaining wall suction pressure at 110-150 mmHg.
• C. Not suctioning for greater than 10-15 seconds at a time.
• D. Applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning.

Correct answer: D

Rationale: The incorrect action by the student is applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning. This technique can cause trauma to the tracheal walls, increasing the risk of injury to the patient. It is essential to perform suctioning gently and without rotation to prevent complications in patients with a tracheostomy. Pre-oxygenating the patient, maintaining appropriate suction pressure, and limiting suctioning time are all correct actions when suctioning a patient with a tracheostomy.

3. The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: In this scenario, the appropriate next step for the healthcare provider is to check for kinks in the tubing and raise the IV pole. These issues can commonly cause a slowed IV rate. Applying a warm compress (Choice A) may not address the underlying problem of kinked tubing or incorrect IV pole height. Adjusting the tape that stabilizes the needle (Choice C) is important for securement but is not the priority in this situation. Flushing with normal saline and recounting the drop rate (Choice D) should only be done after ruling out mechanical issues like kinks in the tubing.

4. During the assessment, a client receiving a continuous infusion of heparin for deep vein thrombosis (DVT) is found to have a nosebleed. Which finding requires immediate action?

• A. The client's activated partial thromboplastin time (aPTT) is 70 seconds.
• B. The client has developed a nosebleed.
• C. The client's blood pressure is 150/90 mm Hg.
• D. The client reports feeling lightheaded.

Correct answer: B

Rationale: A nosebleed (B) in a client receiving heparin is a sign of heparin toxicity and requires immediate action. It indicates that the client is at risk of excessive bleeding. While a prolonged aPTT of 70 seconds (A) is worth monitoring, active bleeding takes precedence. Elevated blood pressure (C) and lightheadedness (D) are potential side effects of heparin but are not as urgently concerning as active bleeding.

5. During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

• A. Provide information about the hours and location of the chapel
• B. Document the statement in the client’s spiritual assessment
• C. Invite the client to a healing service for people of all religions
• D. Offer to contact a spiritual advisor of the client’s choice

Correct answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care. Providing information about the chapel's hours and location (choice A) may not align with the client's beliefs as an agnostic. Inviting the client to a healing service (choice C) assumes the client's interest in such activities, which may not be the case. Offering to contact a spiritual advisor (choice D) may not be necessary if the client did not express a desire for it.

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