Nursing Elites

1. Which of the following interventions promotes patient safety?

• A. Assess the patient’s ability to ambulate and transfer from a bed to a chair
• B. Demonstrate the signal system to the patient
• C. Check to see that the patient is wearing their identification band
• D. All of the above

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

2. A 38-year-old patient’s vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?

• A. Respiratory rate only
• B. Temperature only
• C. Pulse rate and temperature
• D. Temperature and respiratory rate

Correct answer: D

Rationale: Both an elevated temperature and an increased respiratory rate are abnormal vital signs that could indicate an underlying health issue. Reporting both of these findings is crucial to ensure appropriate evaluation and intervention if needed.

3. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

• A. Low back pain.
• B. Dyspnea.
• C. Hypotension.
• D. Thready pulse.

Correct answer: B

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

4. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

• A. Store the glasses in a labeled case.
• B. Clean the glasses with hot water
• C. Clean the glasses with a paper towel.
• D. Store the glasses on the bedside table.

Correct answer: A

Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.

5. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?

• A. Side rails are ineffective
• B. Side rails should not be used
• C. Side rails are a deterrent that prevents a patient from falling out of bed
• D. Side rails are a reminder to a patient not to get out of bed

Correct answer: D

Rationale: The correct conclusion drawn from the study is that side rails serve as a reminder to the patient not to get out of bed rather than being a fail-proof preventive measure against falls. While they may not entirely prevent falls, they play a role in prompting the patient to be cautious when moving.

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