Nursing Elites

1. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

• A. A person of small stature is at increased risk for injury from entrapment.
• B. A history of a previous fall from a bed with raised side rails is significant.
• C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
• D. Creative use of alternative measures indicates respect for the patient's dignity.

Correct answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.

2. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness liquids for her. Water is not a honey thickness liquid. It is much thinner. What should you do?

• A. Tell the resident that she cannot have water.
• B. Give her applesauce instead of the water.
• C. Tell Cheryl that she is NPO until midnight.
• D. Thicken the water and give it to her.

Correct answer: D

Rationale: You can give Cheryl the water that she has requested; however, since water is not a honey-thick liquid as ordered by the doctor, you must thicken it with a commercial thickener before giving it to her. This will ensure that the water is at the appropriate consistency for her swallowing disorder. Choices A, B, and C are incorrect: A) Telling the resident she cannot have water is not the best course of action without attempting to modify it first. B) Giving her applesauce instead of water does not address the specific request for water. C) Placing Cheryl on NPO status until midnight is unnecessary and does not address her immediate request for water.

3. Where is the pulse point located on the top of the foot?

• A. the dorsalis pedis
• B. This is the pulse point checked in patients with peripheral vascular problems.
• C. This pulse point may be absent in some patients due to a congenital anomaly.
• D. All of the above.

Correct answer: D

Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.

4. Mr. and Mrs. K have just adopted a newborn infant and are preparing to take him home from the hospital for the first time. Which safety measure is most appropriate for the clients in this situation?

• A. Turn the handles of pans on the stove inward
• B. Set up a baby gate at the top of the stairs
• C. Cover electrical outlets with child-proof plugs
• D. Install an approved car seat that is facing backward in the back seat

Correct answer: D

Rationale: Parents of newborn infants should use an approved car seat that has been installed facing backward in the back seat of the car. Securing infants in car seats, even from the first ride home from the hospital, promotes safety while transporting. While safety measures at home such as baby gates or outlet covers are important, they are not the priority safety measures until the baby is old enough to be mobile. The car seat is crucial for protecting the newborn during transportation, ensuring proper positioning and restraint in the event of sudden stops or accidents. Turning handles of pans on the stove inward, setting up a baby gate, and covering electrical outlets are important safety measures at home but are not as critical for the immediate safety of a newborn during transportation.

5. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

• A. UAP splint the patient's chest during coughing.
• B. UAP assist the patient to ambulate to the bathroom.
• C. UAP help the patient to a bedside chair for meals.
• D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: D

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

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