Nursing Elites

1. What is the primary purpose of turning and repositioning an immobile patient every 2 hours?

• A. To improve circulation and relieve pressure.
• B. To prevent contractures and muscle atrophy.
• C. To prevent skin breakdown and pressure ulcers.
• D. To improve respiratory function and prevent pneumonia.

Correct answer: C

Rationale: The primary purpose of turning and repositioning an immobile patient every 2 hours is to prevent skin breakdown and pressure ulcers. Prolonged immobility can lead to pressure ulcers, making this a crucial nursing intervention. Choice A is incorrect because while turning can help improve circulation and relieve pressure, the primary purpose is to prevent skin breakdown. Choice B is incorrect as preventing contractures and muscle atrophy is important but not the primary purpose of turning. Choice D is incorrect as improving respiratory function and preventing pneumonia are not directly related to turning and repositioning for skin integrity.

2. A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

• A. Finger
• B. Earlobe
• C. Toe
• D. Skin fold

Correct answer: B

Rationale: When a client has edema of both hands and thickened toenails, these conditions can impede accurate readings from the finger and toe locations. The earlobe is the best alternative site for the pulse oximeter probe in this scenario. Placing the probe on the earlobe will help ensure a more accurate measurement of oxygen saturation despite the issues with the hands and toenails. Therefore, the correct answer is to apply the pulse oximeter probe to the earlobe. Choices A, C, and D are incorrect because of the potential limitations presented by the edema and thickened toenails.

3. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

• A. Loud volume of the television set
• B. Wall-to-wall carpet in the living room
• C. Low chairs without armrests
• D. Use of indirect lighting

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

4. A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (SATA)

• A. Change the client's position
• B. Identify the client's pain level
• C. Remind the client to use incisional splinting
• D. Offer the client a back rub

Correct answer: A

Rationale: The correct actions the nurse should take when caring for a client postoperative following a cholecystectomy and reporting pain include changing the client's position. This can help relieve postoperative pain by reducing pressure on the surgical site. Identifying the client's pain level is important but not specific to alleviating postoperative pain. While reminding the client to use incisional splinting can be beneficial, it may not directly address the immediate pain concern. Offering the client a back rub is not typically indicated for postoperative pain relief after a cholecystectomy.

5. The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

• A. Prepare for potential posttraumatic stress related to this bioterrorism attack.
• B. Transport patients quickly and efficiently through the elevators.
• C. Monitor for specific symptoms related to the bioterrorism attack.
• D. Manage all patients using standard precautions.

Correct answer: D

Rationale: During a potential bioterrorism attack, the priority for the nurse is to manage all patients using standard precautions. This approach ensures the safety of both patients and healthcare providers by preventing the spread of potential bioterrorism-related illnesses. Option A is incorrect because managing patient care and safety through standard precautions takes precedence. Option B is incorrect as patient transport should also be done while adhering to infection control measures. Option C is incorrect as monitoring for specific symptoms is important but not the priority when all patients need to be managed with standard precautions.

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