Nursing Elites

1. A client has restraints on each extremity. Which of the following assessments should the nurse perform first?

• A. Peripheral pulses
• B. Comfort level
• C. Elimination needs
• D. Skin integrity

Correct answer: A

Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.

2. The healthcare professional is assessing a client with a history of rheumatoid arthritis. Which of the following assessment findings would be most concerning?

• A. Morning stiffness
• B. Joint deformities
• C. Fever
• D. Weight loss

Correct answer: C

Rationale: In a client with rheumatoid arthritis, the presence of fever is most concerning because it may indicate an infection or systemic involvement, necessitating immediate attention. Morning stiffness and joint deformities are common manifestations of rheumatoid arthritis itself and are expected findings in these clients. Weight loss can occur in rheumatoid arthritis due to various factors such as decreased appetite or systemic inflammation, but it is not as acutely concerning as fever, which may signal a more urgent issue.

3. The client is advised to take dexamethasone (Decadron) with food or milk. What is the physiological basis for this advice?

• A. Inhibits pepsin production
• B. Stimulates hydrochloric acid production
• C. Delays stomach emptying time
• D. Reduces hydrochloric acid production

Correct answer: B

Rationale: The correct answer is B: Stimulates hydrochloric acid production. Dexamethasone can stimulate the production of hydrochloric acid in the stomach, which may lead to irritation of the stomach lining. Taking dexamethasone with food or milk helps to neutralize or buffer the acid, reducing the risk of stomach irritation. Choice A is incorrect because dexamethasone does not inhibit pepsin production. Choice C is incorrect as dexamethasone does not slow stomach emptying time. Choice D is incorrect as dexamethasone does not reduce hydrochloric acid production.

4. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?

• A. Carbon monoxide does not have a distinct odor.
• B. Water heaters should be inspected every 5 years.
• C. The lungs are not damaged from carbon monoxide inhalation.
• D. Carbon monoxide binds with hemoglobin in the body.

Correct answer: D

Rationale: The correct answer is D: 'Carbon monoxide binds with hemoglobin in the body.' Carbon monoxide is an odorless, colorless gas, so it does not have a distinct odor (Choice A). While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning (Choice B). Carbon monoxide primarily affects the cardiovascular system by binding with hemoglobin, reducing the blood's ability to carry oxygen, rather than causing direct lung damage (Choice C). Understanding how carbon monoxide binds with hemoglobin is crucial in recognizing the mechanism of poisoning and its potential consequences.

5. The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.

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