Nursing Elites

1. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?

• A. Immediately do a complete head-to-toe neurological assessment.
• B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
• C. Place a blanket over the feet.
• D. Remove the restraint.

Correct answer: D

Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.

2. The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?

• A. Loss of weight
• B. Loss of bone mass
• C. Loss of hope
• D. Loss of strength

Correct answer: C

Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.

3. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?

• A. Give detailed information about the medication, including its potential side effects.
• B. Refer the client to the healthcare provider for more information.
• C. Give a brief explanation and administer the medication.
• D. Ask another nurse to explain the medication and proceed.

Correct answer: B

Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.

4. What is the most important nursing intervention for a patient with diarrhea?

• A. Encourage the patient to increase fluid intake.
• B. Monitor the patient's skin integrity.
• C. Check the patient's electrolyte levels.
• D. Educate the patient about infection control measures.

Correct answer: B

Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.

5. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?

• A. Drink fluids between meals
• B. Eat three large meals each day
• C. Lie down for 30 minutes after meals
• D. Avoid drinking liquids with meals

Correct answer: D

Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.

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