Nursing Elites

1. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

• A. Remove the restraints from the client's wrists
• B. Review the chart for nonrestraint alternatives for agitation
• C. Speak with the AP about the incident
• D. Inform the unit manager of the incident

Correct answer: A

Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.

2. Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?

• A. Administer glyburide again
• B. Administer subcutaneous insulin and monitor blood glucose
• C. Monitor blood glucose closely, and look for signs of hypoglycemia
• D. Monitor blood glucose and assess for signs of hyperglycemia

Correct answer: C

Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.

3. Which of the following is a benefit of the U.S. health-care system?

• A. With cost savings from technology, more Americans now have health-care insurance.
• B. Quality of care has improved in the United States.
• C. Care in the United States has shifted to a prevention focus rather than an illness focus.
• D. The use of technology is projected to decrease health-care costs and improve clinical outcomes.

Correct answer: D

Rationale: The correct answer is D because the use of technology and electronic health records is projected to decrease health-care costs and improve clinical outcomes, quality, and safety. Choice A is incorrect because it states that very few Americans have no health-care insurance, which is not a benefit of the U.S. health-care system. Choice B may be true, but it does not directly address a benefit of the health-care system. Choice C is not necessarily a benefit but rather a shift in focus, so it is also incorrect.

4. A nurse manager is receiving report and is faced with the following situations that require intervention. Which of the following should the nurse manager address first?

• A. No transport assistance is available to take the client to PT.
• B. A client is refusing care from an AP of the opposite gender.
• C. Three staff members have called to say they will be absent.
• D. Two nurses had a heated disagreement about a scheduling issue.

Correct answer: C

Rationale: The correct answer is C. Addressing the absence of three staff members should be the nurse manager's priority as it directly impacts staffing levels and patient care. This situation can lead to staffing shortages, affecting patient safety and workload distribution. Option A, lack of transport assistance, although important, can be addressed after ensuring adequate staffing. Option B involves a client's preference and can be addressed by assigning care appropriately. Option D, a disagreement between two nurses, is important but can be addressed after ensuring adequate staffing and patient care.

5. Which of the following is considered an internal disaster?

• A. A patient fall
• B. The massive spread of pneumonia
• C. A computer hacking episode
• D. Unexpected staff absences due to illness

Correct answer: C

Rationale: A computer hacking episode is considered an internal disaster as it disrupts the internal operations of the healthcare facility, compromising data security and potentially impacting patient care. Choices A, B, and D do not directly relate to internal disasters in a healthcare setting. A patient fall is a patient safety issue, the massive spread of pneumonia is a public health concern, and unexpected staff absences due to illness may affect staffing levels but are not typically classified as internal disasters.

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