Nursing Elites

1. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

• A. We need to document the exact medication you were taking because you might be allergic to it.
• B. You should take a different type of antibiotic this time.
• C. A rash is a common reaction and is not usually concerning.
• D. You can take the same antibiotic again if needed.

Correct answer: A

Rationale: The nurse should advise the client to document the exact medication taken to identify potential allergies and prevent adverse reactions. This is important as the client developed a rash previously while taking an antibiotic, indicating a possible allergic reaction. Choice B is not appropriate as switching antibiotics without proper evaluation can be risky. Choice C is incorrect as rashes should not be dismissed without further investigation, especially in the context of taking medication. Choice D is also not recommended as re-taking the same antibiotic without clarifying the allergic reaction can lead to a potentially severe outcome.

2. A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?

• A. Tie the restraint with a quick-release knot.
• B. Use a slipknot to secure the restraint.
• C. Ensure the restraint is tightly secured.
• D. Attach the restraint to the bed frame.

Correct answer: A

Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.

3. The healthcare professional is evaluating the body alignment of a patient in the sitting position. Which observation will indicate a normal finding?

• A. The edge of the seat is making contact with the popliteal space.
• B. Both feet are supported on the floor with ankles flexed.
• C. The body weight is solely on the buttocks.
• D. The arms hang comfortably at the sides.

Correct answer: B

Rationale: In a normal sitting position, both feet should be supported on the floor with the ankles comfortably flexed. This position helps in maintaining stability and proper alignment. Choice A is incorrect because the edge of the seat pressing against the popliteal space may cause discomfort and is not indicative of proper alignment. Choice C is incorrect as the body weight should be evenly distributed for proper alignment and comfort, not solely on the buttocks. Choice D is incorrect as the position of the arms alone does not indicate proper body alignment in the sitting position; proper arm positioning is important for comfort but not a key indicator of body alignment.

4. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action:

• A. May result in charges of unlawful seclusion and restraint
• B. Leaves the nurse vulnerable to charges of assault and battery
• C. Was appropriate given the client's history of violence
• D. Was necessary to maintain the therapeutic milieu of the unit

Correct answer: A

Rationale: Placing a client in seclusion without proper justification and documentation can lead to charges of unlawful seclusion and restraint, regardless of the client's compliance. This legal issue arises from the potential violation of the client's rights and must be avoided. Choice B is incorrect as the situation does not involve assault and battery. Choice C is incorrect as past violence alone does not justify seclusion without immediate risk. Choice D is incorrect as seclusion should be used based on individual risk and necessity, not solely for maintaining the therapeutic milieu.

5. The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?

• A. I will stop taking the medication if I experience dizziness.
• B. I will monitor my blood pressure regularly.
• C. I will avoid drinking alcohol while taking this medication.
• D. I will rise slowly from a sitting to a standing position.

Correct answer: A

Rationale: The correct answer is A. Stopping antihypertensive medication abruptly can lead to rebound hypertension, which can be dangerous. Clients should never discontinue their medication without consulting their healthcare provider first. Choice B is correct because monitoring blood pressure is essential when taking antihypertensive medication to ensure it stays within the target range. Choice C is correct as alcohol can potentiate the hypotensive effects of antihypertensive medications. Choice D is correct as orthostatic hypotension can occur, so rising slowly helps prevent dizziness and falls. Therefore, choice A is the statement that indicates a need for further teaching.

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