Nursing Elites

1. A client who is confused and pulling at the tubing of her IV is being cared for by a nurse. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider?

• A. Place the client in a room away from the nurses’ station.
• B. Limit the client’s visitors.
• C. Give the client washcloths to fold.
• D. Close the door of the client’s room.

Correct answer: C

Rationale: Providing the client with washcloths to fold is a non-restrictive intervention that can help distract and engage the client, potentially reducing the need for restraints. This action promotes a therapeutic and calming environment for the confused client. Placing the client in a room away from the nurses’ station (Choice A) may not address the underlying issue of confusion and agitation. Limiting the client’s visitors (Choice B) may not directly assist in managing the client's behavior. Closing the door of the client’s room (Choice D) does not actively engage the client in a therapeutic intervention to address the behavior.

2. While providing care to a group of patients, which patient should the nurse prioritize seeing first?

• A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
• B. A bedridden patient with a reddened area on the buttocks who needs to be turned
• C. A patient on bed rest with renal calculi who needs to go to the bathroom
• D. A patient post-knee surgery who needs range of motion exercises

Correct answer: A

Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.

3. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

• A. Abnormal breath sounds
• B. Cyanosis of the lips
• C. Increasing pulse rate
• D. Pulse oximeter reading of 92%

Correct answer: C

Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.

4. 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.

5. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take?

• A. Alert the American Nurses Association.
• B. Fill out an incident report.
• C. Report the observations to the nurse manager on the unit.
• D. Leave the nurse alone to sleep.

Correct answer: C

Rationale: Reporting the observations to the nurse manager is the appropriate action to ensure the safety of the clients and address potential impairment. The nurse manager can take necessary steps to assess the situation and intervene if needed. Alerting the American Nurses Association (Choice A) is not necessary at this stage as the immediate concern is the safety of clients in the unit. Filling out an incident report (Choice B) may be required later, but the priority is to address the issue promptly by involving the immediate supervisor. Leaving the nurse alone to sleep (Choice D) is not a safe option as it does not address the underlying problem of potential impairment and safety concerns; it is essential to address the issue promptly to ensure patient safety.

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