Nursing Elites

1. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take?

• A. Remove the restraints every 4 hours.
• B. Attach the restraints securely to the side of the client's bed.
• C. Apply the restraints to allow as little movement as possible.
• D. Allow room for two fingers to fit between the client's skin and the restraints.

Correct answer: D

Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security. Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use. Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client. Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.

2. A client has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage?

• A. Supine and low Fowler's position
• B. Right lateral in Trendelenburg position
• C. Side lying with the right side of the chest elevated
• D. Prone with pillows under the extremities

Correct answer: B

Rationale: Postural drainage is a technique used to help remove secretions from specific lung segments. For left lower atelectasis, placing the client in the right lateral Trendelenburg position is most effective. This position helps target the affected area, using gravity to assist in drainage. Placing the client in a supine or low Fowler's position (Choice A) may not effectively target the affected area. Side lying with the right side of the chest elevated (Choice C) would not utilize gravity for optimal drainage. Placing the client prone with pillows under the extremities (Choice D) is not ideal for postural drainage of the left lower lobe.

3. A healthcare professional is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the healthcare professional initiate?

• A. Contact
• B. Droplet
• C. Airborne
• D. Protective

Correct answer: B

Rationale: The correct answer is B: Droplet. Droplet precautions are required for infections that spread via droplets larger than 5 microns in diameter, such as pharyngeal diphtheria. Contact precautions are used for diseases that spread by direct or indirect contact. Airborne precautions are for diseases that spread through small particles in the air. Protective precautions are not a standard precautionary measure for specific infections like pharyngeal diphtheria.

4. To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?

• A. Every 4 to 8 hours
• B. Every 12 to 24 hours
• C. Every 24 to 48 hours
• D. Every 72 to 96 hours

Correct answer: D

Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.

5. What instruction should the nurse provide for a UAP caring for a client with MRSA who has a prescription for contact precautions?

• A. Allow visitors with precautions in place
• B. Wear sterile gloves when handling the client's body fluid
• C. Have the client wear a mask whenever someone enters the room
• D. Don a gown and gloves when entering the room

Correct answer: D

Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the room. Wearing a gown and gloves is necessary to prevent the transmission of MRSA. Choice A is incorrect because visitors may be allowed with proper precautions in place. Choice B is incorrect as it assumes the client has body fluid precautions, which is not specified. Choice C is incorrect as it does not address the UAP's protective measures but rather focuses on the client wearing a mask.

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