Nursing Elites

1. Which intervention is most effective for managing a patient with constipation?

• A. Increase the patient's fluid intake.
• B. Administer a stool softener as prescribed.
• C. Provide the patient with a high-fiber diet.
• D. Teach the patient to perform Valsalva maneuvers.

Correct answer: B

Rationale: The most effective intervention for managing constipation in a patient is to administer a stool softener as prescribed. Stool softeners help relieve constipation by making the stool easier to pass, especially in postoperative patients. Increasing fluid intake can be beneficial but may not address the underlying cause of constipation. While a high-fiber diet is important for bowel health, it may not provide immediate relief for constipation. Teaching a patient to perform Valsalva maneuvers is not recommended for managing constipation as it can lead to adverse effects like increasing intra-abdominal pressure.

2. How should a healthcare professional position a patient to reduce the risk of pressure ulcers?

• A. Position the patient in the supine position for long periods.
• B. Use pillows to support bony prominences.
• C. Turn the patient every 4 hours.
• D. Place the patient on an alternating pressure mattress.

Correct answer: B

Rationale: Correctly positioning a patient to reduce the risk of pressure ulcers involves using pillows to support bony prominences. This helps to relieve pressure from vulnerable areas and prevent the development of pressure ulcers. Choice A is incorrect because keeping a patient in the supine position for extended periods can increase the risk of pressure ulcers. Choice C is incorrect as turning the patient every 2 hours, rather than every 4 hours, is recommended to prevent pressure ulcers. Choice D is not the best option mentioned for positioning a patient to reduce pressure ulcer risk; although alternating pressure mattresses can be beneficial, using pillows for support is a more direct and commonly used method.

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 preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

• A. Check for orthostatic hypotension
• B. Use a gait belt
• C. Position the chair on the strong side
• D. Ask for assistance

Correct answer: A

Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.

5. When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?

• A. Check for respiratory depression.
• B. Assess pain control.
• C. Check the infusion site for complications.
• D. Monitor the client's blood pressure.

Correct answer: A

Rationale: The correct answer is to check for respiratory depression first when assessing a client receiving a continuous intravenous infusion of morphine sulfate. Respiratory depression is the most common life-threatening side effect associated with morphine administration. Monitoring respiratory status is crucial as it can quickly deteriorate, leading to serious complications or even respiratory arrest. Assessing pain control (choice B) is important but ensuring adequate ventilation takes precedence. Checking the infusion site for complications (choice C) and monitoring blood pressure (choice D) are also essential aspects of care but are secondary to evaluating respiratory status when administering morphine.

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