Nursing Elites

1. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?

• A. Apply the restraints to ensure the client's safety.
• B. Reassess the client to determine if restraints are still necessary.
• C. Document the time the family departed and continue monitoring the client.
• D. Contact the healthcare provider for a new order.

Correct answer: B

Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.

2. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

• A. Removing the empty food tray from a client with a urinary catheter.
• B. Washing and combing the hair of a client with a fractured leg in traction.
• C. Administering oral medications to a cooperative client with a wound infection.
• D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

3. Which nonverbal action should be implemented to demonstrate active listening?

• A. Sit facing the individual.
• B. Cross arms and legs.
• C. Avoid eye contact.
• D. Lean back in the chair.

Correct answer: A

Rationale: To demonstrate active listening effectively, it is essential to display open and engaging body language. Sitting facing the individual helps convey attentiveness and a willingness to listen. Maintaining eye contact further enhances the connection and shows respect and interest in the conversation. Crossing arms and legs can create a barrier and signal defensiveness or disinterest. Avoiding eye contact may suggest a lack of engagement or attentiveness. Leaning back in the chair can indicate relaxation but might be perceived as disengagement. Therefore, the most appropriate nonverbal action to demonstrate active listening is to sit facing the individual and maintain eye contact.

4. The client is being taught how to perform active range of motion (ROM) exercises. To exercise the hinge joints, which action should the client be instructed to perform?

• A. Tilt the pelvis forwards and backwards
• B. Bend the arm by flexing the ulnar to the humerus
• C. Turn the head to the right and left
• D. Extend the arm at the side and rotate it in circles

Correct answer: B

Rationale: Hinge joints, like the elbow, primarily allow movement in one direction, in this case, bending the arm. The correct action to exercise hinge joints is to bend the arm by flexing the ulnar to the humerus. This movement specifically targets the hinge joint and promotes its range of motion. Choices A, C, and D involve movements that do not specifically target hinge joints. Tilt the pelvis involves the ball-and-socket joints of the hip, turning the head involves the pivot joint of the neck, and extending the arm and rotating it in circles involve multiple joints including ball-and-socket and pivot joints.

5. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take?

• A. Record the coughing incident. No further action is required at this time.
• B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
• C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
• D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Correct answer: C

Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small-bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes. The nurse should assess tube placement in this way before taking any other action to ensure the tube is still in the correct position and prevent potential complications. Choice A is incorrect because further assessment is needed due to the risk of tube displacement. Choice B is incorrect as stopping the feeding and involving the family is premature without confirming tube placement. Choice D is incorrect as injecting air and auscultating for gurgling is not the recommended method to confirm tube placement.

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