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. What is the most appropriate method for assessing a patient's pain level?

• A. Observe the patient's facial expressions.
• B. Use a standardized pain scale, such as 0-10.
• C. Ask the patient to rate their pain based on their mood.
• D. Ask the patient's family members to assess the pain.

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

3. While reviewing a client's chart, a nurse notices a discrepancy in the medication record. What should the nurse do?

• A. Correct the discrepancy and document the correction.
• B. Report the discrepancy to the nurse manager.
• C. Ignore the discrepancy assuming it is a clerical error.
• D. Discuss the discrepancy with the client and adjust the records.

Correct answer: B

Rationale: Reporting medication discrepancies to the nurse manager is crucial to ensure patient safety and proper follow-up. The nurse manager is responsible for addressing medication errors and implementing necessary corrective actions. Choice A is incorrect because simply correcting the discrepancy without reporting it may lead to potential harm to the patient and violates professional standards. Choice C is incorrect as ignoring the discrepancy increases the risk of medication errors going unresolved. Choice D is incorrect because discussing the discrepancy with the client before verifying the accuracy of the record can cause confusion and compromise patient safety.

4. What are the key considerations when administering medication via a nasogastric (NG) tube?

• A. Checking tube placement before administration
• B. Administering medication in liquid form whenever possible
• C. Crushing tablets and mixing them with water if needed
• D. Flushing the NG tube with water before and after medication

Correct answer: A

Rationale: The correct answer is A: Checking tube placement before administration. This is a crucial step to ensure that the medication reaches the stomach safely and does not end up in the lungs, which can lead to serious complications. Choice B is incorrect as not all medications can be administered in liquid form. Choice C is incorrect because crushing tablets can alter their effectiveness or cause harm. Choice D is incorrect as flushing the NG tube with water is not a standard practice before administering medication, unless specified by healthcare provider instructions.

5. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

• A. Straps with quick-release buckles attached to bed side rails.
• B. Attempts to distract the patient with television are unsuccessful.
• C. Bilateral radial pulses present, 2+, hands warm to the touch.
• D. Released from restraints, active range-of-motion exercises completed.

Correct answer: C

Rationale: The correct answer is C because documenting bilateral radial pulses being present, 2+, and hands warm to the touch is crucial when caring for a patient in restraints. This information helps in monitoring circulation and assessing the patient's well-being. Choices A, B, and D are incorrect because they do not provide essential information related to the patient's safety and well-being while in restraints.

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