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. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

• A. Brachial pulse in the right arm
• B. Radial pulse in the right arm
• C. Brachial pulse in the left arm
• D. Radial pulse in the left arm

Correct answer: D

Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.

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 client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?

• A. Administer pain medication.
• B. Elevate the limb and monitor closely.
• C. Encourage movement to reduce swelling.
• D. Notify the provider immediately about the symptoms.

Correct answer: D

Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.

5. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?

• A. Obtain a detailed medical history
• B. Administer nitroglycerin
• C. Conduct an ECG
• D. Administer morphine sulfate

Correct answer: B

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.

Similar Questions