Nursing Elites

1. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?

• A. Administer nasal oxygen at a rate of 5 L/min
• B. Help the client to lie back down in the bed
• C. Quickly pivot the client to the chair and elevate the legs
• D. Check the client’s blood pressure and pulse

Correct answer: D

Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.

2. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

• A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
• B. Instruct the UAP not to wake the client under any circumstances during the night.
• C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
• D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Correct answer: A

Rationale: The best action for the nurse is to determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. By incorporating familiar bedtime rituals that do not compromise the client's safety, the nurse can help the client fall asleep faster and improve the overall quality of care provided to the client.

3. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?

• A. Use disposable plates and utensils.
• B. Stay in a room with the door closed.
• C. Dispose of soiled dressings in plastic bags that are securely closed.
• D. Others who are in the same room with the client should wear a mask.

Correct answer: C

Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.

4. During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?

• A. The client can hear a whisper from 1 to 2 feet away.
• B. The client can identify an object by touch.
• C. The client can shrug the shoulders against resistance.
• D. The client can read a Snellen chart from 20 feet away.

Correct answer: D

Rationale: The ability to read a Snellen chart from 20 feet away indicates intact cranial nerve II (optic nerve), responsible for vision. Hearing a whisper (A) is associated with cranial nerve VIII (vestibulocochlear nerve), identifying an object by touch (B) is related to cranial nerves V (trigeminal nerve) and VII (facial nerve), and shoulder shrugging against resistance (C) is a test for cranial nerve XI (accessory nerve). Thus, the correct answer is D as it specifically tests the function of cranial nerve II.

5. 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.

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