Nursing Elites

1. When turning an immobile bedridden client without assistance, which action best ensures client safety?

• A. Securely grasp the client's arm and leg.
• B. Put bed rails up on the side of bed opposite from the nurse.
• C. Correctly position and use a turn sheet.
• D. Lower the head of the client's bed slowly.

Correct answer: B

Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.

2. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

• A. Cleanse the stoma with hydrogen peroxide and water.
• B. Apply a moisture barrier cream to the peristomal skin.
• C. Measure the stoma using a stoma guide.
• D. Use a dry gauze pad to clean the stoma.

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

3. The client with cholecystitis is being instructed on dietary choices. Which meal best meets the dietary needs of this client?

• A. Steak, baked beans, and a salad
• B. Broiled fish, green beans, and an apple
• C. Pork chops, macaroni and cheese, and grapes
• D. Avocado salad, milk, and angel food cake

Correct answer: B

Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.

4. The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to the daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine currently followed.

Correct answer: D

Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.

5. A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?

• A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
• B. Notify the healthcare provider and request a prescription for a large-volume enema.
• C. Assess the client's medical record to determine the client's normal bowel pattern.
• D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Correct answer: C

Rationale: When a client reports a change in bowel habits, the first step for the nurse is to assess the client's normal bowel pattern by reviewing the medical records. This assessment helps the nurse understand the client's baseline, which is crucial before initiating any interventions. By determining the client's usual bowel habits, the nurse can identify deviations from the norm and make informed decisions on the appropriate course of action. Assessing the client's medical record is a critical first step in addressing the client's bowel concerns. Choices A, B, and D are incorrect because they jump to interventions without first establishing the client's normal bowel pattern. Offering warm prune juice, requesting a large-volume enema, or increasing fluids may not be appropriate until the nurse knows the client's regular bowel habits and can assess the situation effectively.

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