Nursing Elites

1. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?

• A. Place the call light within the patient's reach.
• B. Apply a yellow fall risk bracelet to the patient.
• C. Assist the patient when ambulating.
• D. Ensure the patient's room is well-lit.

Correct answer: B

Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.

2. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?

• A. Hypertension, bradycardia, and oliguria
• B. Bradycardia, hypertension, and peripheral edema
• C. Tachypnea, cool skin, and confusion
• D. Tachycardia, hypotension, and decreased urine output

Correct answer: D

Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.

3. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?

• A. Do not change the mask if the nurse is comfortable.
• B. Change the mask when relieved by the next shift.
• C. Apply a new mask.
• D. Reapply the mask after it air-dries.

Correct answer: C

Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.

4. A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?

• A. Diarrhea
• B. Vomiting
• C. Ringing in ears
• D. Dizziness

Correct answer: B

Rationale: The correct answer is B: Vomiting. Vomiting is a common sign of digoxin toxicity and should be reported to the healthcare provider. Diarrhea (Choice A) is a more common side effect of digoxin but not typically associated with toxicity. Ringing in the ears (Choice C) is a potential sign of toxicity; however, vomiting is a more immediate concern. Dizziness (Choice D) can occur with digoxin use but is not a specific indicator of toxicity.

5. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

• A. Hold the cane with your left hand
• B. Move the cane forward 18 inches with each step
• C. When walking, move your left foot forward first
• D. Keep your elbow straight when you hold the cane

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

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