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. Round off these numbers to the nearest tenth:

• A. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
• B. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
• C. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
• D. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7

Correct answer: B

Rationale: The correct answer is B. When rounding off to the nearest tenth, 1.027 becomes 1.0 because the digit in the hundredth's place is less than 5. For the other numbers, they are rounded correctly to the nearest tenth: 5.5778 = 5.6, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7. Therefore, option B is the most accurate in rounding off these numbers to the nearest tenth. Choices A, C, and D are incorrect as they do not round 1.027 to 1.0 as required when rounding to the nearest tenth.

3. A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

• A. Withhold the benzodiazepine but continue the opioid
• B. Contact the provider about replacing the opioid with an NSAID
• C. Administer the benzodiazepine but withhold the opioid
• D. Continue the medication dosages that relieve the client's pain

Correct answer: B

Rationale: The correct action for the nurse to take is to contact the provider about replacing the opioid with an NSAID. In this scenario, the client is experiencing excessive sedation after the administration of both opioid and benzodiazepine. Switching to a non-opioid analgesic like an NSAID can help manage pain effectively without causing additional sedation. Option A is incorrect because continuing the opioid may exacerbate sedation. Option C is incorrect as administering the benzodiazepine may further increase sedation. Option D is incorrect because maintaining the current medication dosages that are causing excessive sedation is not in the client's best interest.

4. A nurse enters the hallway and discovers a visitor looking at a client's medical information on a computer. Which of the following actions should the nurse take first?

• A. Inform the care nurse that a visitor viewed a client's protected health information.
• B. Close the documentation program on the computer.
• C. Inform the visitor that the client's records are confidential.
• D. Find out which staff member left the documentation program on the screen.

Correct answer: B

Rationale: The correct first action for the nurse to take is to close the documentation program on the computer to prevent further unauthorized access to the client's medical information. Choice A is incorrect because the immediate concern is to secure the information first. Choice C, while important, can be addressed after securing the information. Choice D, finding out which staff member left the program open, is not the immediate priority when patient confidentiality is at risk.

5. What does the mnemonic PERLA stand for in the assessment of the eyes?

• A. Pupils equally reactive to light and accommodation
• B. Patient eyes are equally recessed and responsive to light and acuity
• C. Patient eyes are equally responsive to light and acuity
• D. Pupils equally reactive to light and acuity

Correct answer: A

Rationale: The correct answer is A: 'Pupils equally reactive to light and accommodation.' PERLA is a mnemonic used in eye assessments to check for Pupils being equally reactive to Light and Accommodation. Choice B is incorrect as it includes irrelevant information about the eyes being recessed. Choice C is incorrect as it is missing the mention of pupils and accommodation. Choice D is incorrect as it misses the mention of accommodation.

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