Nursing Elites

1. What is the most effective way to prevent skin breakdown?

• A. assistive devices
• B. repositioning
• C. topical medications
• D. avoiding tape and bandages

Correct answer: V

Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (Choice A) may be beneficial in some cases, they are not universally as effective as repositioning. Topical medications (Choice C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (Choice D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.

2. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?

• A. "You really need to listen to what the physician says."?
• B. "You will get too tired to take care of him at home."?
• C. "What can I do to assist you to care for him at home?"?
• D. "You are too busy to be taking care of an elderly person."?

Correct answer: C

Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.

3. Regardless of their practice area, nurses should be concerned with:

• A. all drug-resistant bacteria.
• B. microorganisms that are critical.
• C. transmission of microorganisms.
• D. overprescription of bacteriostatic drugs.

Correct answer: C

Rationale: All nurses should be concerned with preventing the transmission of microorganisms to themselves and others. A primary way to achieve this is through asepsis. Nursing practice emphasizes providing a safe environment to shield clients, family, and healthcare providers from infections. Choices A, B, and D are incorrect. While drug-resistant bacteria, critical microorganisms, and overprescription of bacteriostatic drugs are important, nurses' primary focus should be on preventing microorganism transmission to ensure safety and well-being.

4. What is the appropriate intervention for a client who is restrained?

• A. Remove the restraints and provide skin care every hour.
• B. Document the condition of the client's skin every 3 hours.
• C. Assess the restraint every 30 minutes
• D. Tie the restraint to the side rails.

Correct answer: C

Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.

5. Which of the following is not one of the four categories related to client care plans?

• A. privacy
• B. evaluation
• C. diagnosis
• D. outcome

Correct answer: A

Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.

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