When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly. (ANS - B. Rationale :Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause clie nt injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed r The nurse identifies a potential for infection in a client with partial -thickness (second -degree) and full -thickness (third -degree) burns. What action has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful hand washing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns (ANS - B Careful hand washing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level (ANS - A Rationale: Long -term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) a re available. Albumin has a long half -life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half -life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinic al measures of protein malnutrition. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered. (ANS - C Rationale: It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed.
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