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. 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.

3. Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?

• A. Shaving the neck.
• B. Establishing a means of communication.
• C. Inserting a Foley catheter.
• D. Starting an IV.

Correct answer: B

Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.

4. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?

• A. Remind the client that her parents have passed away
• B. Ask the client about her favorite memories with her parents
• C. Engage the client in an activity to distract her from thinking about her parents
• D. Reorient the client to the present reality and surroundings

Correct answer: C

Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.

5. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and that the reading needs to be verified by another nurse.
• B. Contact the healthcare provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.

Similar Questions