Nursing Elites

1. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

• A. Keep all of the side rails up
• B. Review prescribed medications
• C. Complete the "get up and go"? test
• D. Place the bed in the lowest position

Correct answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.

2. Which of the following is part of client teaching regarding antiembolism stockings?

• A. Instruct the client to roll the top portion of the stocking down if it is too long
• B. Stockings are applied with the toes uncovered at the end
• C. Measure for thigh-high stockings from the foot to the knee
• D. Stockings are to be smooth from end to end without wrinkles

Correct answer: D

Rationale: When educating clients about antiembolism stockings, it is essential to emphasize that the stockings should be smooth from end to end without wrinkles. Wrinkles in the stockings can impede circulation, defeating the purpose of wearing them to prevent blood clot formation. Instructing the client to roll the top portion of the stocking down if it is too long (Choice A) is incorrect as it can create unnecessary pressure points. Stockings should be applied with the toes covered at the end (Choice B) to ensure proper compression. Measuring for thigh-high stockings should be done from the knee to the foot (Choice C) to ensure the correct fit and compression gradient.

3. Which of the following tests would MOST LIKELY be performed on a patient who is being monitored for coagulation therapy?

• A. PT/INR
• B. CBC
• C. PTT
• D. WBC

Correct answer: A

Rationale: The correct answer is A: PT/INR. Prothrombin times (PT/INR) are commonly used to monitor patients on Coumadin (warfarin) therapy, an anticoagulant that slows the blood's ability to clot. Monitoring PT/INR levels helps ensure the patient is receiving the appropriate dosage of Coumadin. Choice B, CBC (Complete Blood Count), is a general test that provides information on red blood cells, white blood cells, and platelets but is not specific to monitoring coagulation therapy. Choice C, PTT (Partial Thromboplastin Time), is another coagulation test but is not as commonly used for monitoring Coumadin therapy. Choice D, WBC (White Blood Cell count), is unrelated to monitoring coagulation therapy and is used to assess immune system function.

4. A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up."? Which nursing intervention should have the highest priority?

• A. Self-esteem-building activities
• B. Anxiety self-control measures
• C. Sleep enhancement activities
• D. Suicide precautions

Correct answer: D

Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.

5. When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?

• A. Notify the physician.
• B. Record this finding as normal.
• C. Check the child's blood pressure and note any variation with respiration.
• D. Document that this child has bradycardia and continue with the assessment.

Correct answer: B

Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.

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