Nursing Elites

1. Why is padding on a restraint helpful?

• A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
• B. To help the client feel more secure.
• C. To keep infection and wounds at bay.
• D. To keep restraints in place.

Correct answer: A

Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.

2. The nurse is teaching a client about communicable diseases and explains that a portal of entry is:

• A. a vector.
• B. a source, like contaminated water.
• C. food.
• D. the respiratory system.

Correct answer: D

Rationale: The correct answer is 'the respiratory system.' A portal of entry is the path through which a microorganism enters the body. In the case of communicable diseases, the respiratory system can serve as a portal of entry for pathogens such as viruses or bacteria. Choices A, B, and C are incorrect. A 'vector' is an organism that transmits disease, not the entry point for pathogens. Contaminated water or food can act as sources or reservoirs of disease-causing microorganisms, not portals of entry.

3. Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?

• A. "I should provide a regular schedule for toileting."?
• B. "I should talk to my father less because he can't communicate."?
• C. "I should give my father oral care after every meal and bedtime."?
• D. "I should assist my father with eating and drinking."?

Correct answer: B

Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual. Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.

4. What is the best definition of ethics in nursing?

• A. advocating for the client
• B. knowing your scope of practice
• C. being able to differentiate right from wrong
• D. being willing to report violations

Correct answer: C

Rationale: Ethics in nursing refers to the moral principles that govern a nurse's behavior and decision-making. It involves being able to differentiate right from wrong, making choices that are morally sound, and upholding integrity in patient care. While advocating for the client (choice A) is an important aspect of nursing care, it does not fully encompass the broad concept of ethics. Knowing your scope of practice (choice B) is essential for safe and competent care but is not a comprehensive definition of ethics. Being willing to report violations (choice D) is part of ethical practice, but it is not the core definition of ethics in nursing.

5. What should be the primary action for a client who has just vomited 300 cc of bright red blood?

• A. Document the vomiting.
• B. Increase IV fluids.
• C. Get a complete blood count.
• D. Check the blood pressure.

Correct answer: D

Rationale: The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.

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