Nursing Elites

1. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

• A. Maintain the client in a lateral position using protective wrist and vest restraints.
• B. Position the client prone with a small pillow below the diaphragm.
• C. Raise the head and knee gatch when lying in a supine position.
• D. Transfer the client to a wheelchair close to the nursing station for observation.

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

2. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

• A. Notify the charge nurse that a medication error occurred.
• B. Submit a medication variance report to the supervisor.
• C. Document the events that occurred in the nurse's notes.
• D. Discard the original medication administration record.

Correct answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care. Notifying the charge nurse or submitting a medication variance report may not be necessary as the situation was managed appropriately, and discarding the original medication administration record is not recommended as it is part of the client's medical record and should be kept for documentation purposes.

3. UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube
• B. The urine meter attached to the urinary drainage bag is completely full
• C. There is a large dependent loop in the client’s urinary drainage tubing
• D. Purulent drainage is present around the insertion site of the feeding tube

Correct answer: D

Rationale: Purulent drainage indicates infection at the insertion site, which requires immediate attention to prevent complications.

4. Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?

• A. Instruct the client in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique when changing the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: Thrombus formation is a risk for clients who are immobile postoperatively. Encouraging frequent ambulation helps to prevent stasis in the lower extremities, reducing the risk of thrombus formation. This intervention promotes circulation and prevents blood clot formation, making it the most important intervention in this situation.

5. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?

• A. Release the suction by opening the vent.
• B. Continue suctioning to remove obstruction.
• C. Increase the pressure.
• D. Suction deeper.

Correct answer: A

Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.

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