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. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?

• A. To comply with legal requirements for documenting lesions.
• B. To meet hospital policies for documenting lesions.
• C. To fulfill physician's documentation requirements for lesions.
• D. Because the nursing assessment of ulcers is a standard of nursing practice.

Correct answer: D

Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.

3. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

• A. Rechecking the pulse oximetry reading
• B. Calling the respiratory therapist
• C. Calling the healthcare provider
• D. Oxygenating the client with 100% oxygen

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

4. What is the role of the incident report in risk management?

• A. Liability protection.
• B. To provide data for analysis by a risk manager to determine how future problems can be avoided.
• C. To discipline staff for errors.
• D. All of the above.

Correct answer: B

Rationale: The correct answer is 'To provide data for analysis by a risk manager to determine how future problems can be avoided.' Incident reports are a crucial tool for collecting information about incidents to analyze them and prevent similar issues in the future. They are not primarily used for liability protection or disciplining staff. Therefore, choices A and C are incorrect. Selecting 'All of the above' (choice D) is not accurate as incident reports serve a specific purpose related to data analysis and risk prevention, excluding liability protection and staff discipline.

5. When removing a client's gown with an intravenous line, what should the nurse do?

• A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown
• B. cut the gown with scissors
• C. thread the bag and tubing through the gown sleeve, keeping the line intact
• D. temporarily disconnect the tubing from the intravenous container and thread it through the gown

Correct answer: C

Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.

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