Nursing Elites

1. The client with schizophrenia has become disruptive and requires seclusion. Which staff member can institute seclusion?

• A. The security guard
• B. The registered nurse
• C. The licensed practical nurse
• D. The nursing assistant

Correct answer: B

Rationale: The registered nurse is the correct choice to institute seclusion for a client with schizophrenia. In healthcare settings, only a registered nurse or a physician can legally initiate seclusion. The security guard, licensed practical nurse, and nursing assistant do not have the authority to carry out this action. Therefore, options A, C, and D are incorrect.

2. What is the first exercise that should be performed by a client who had a mastectomy?

• A. Walking the hand up the wall
• B. Sweeping the floor
• C. Combing her hair
• D. Squeezing a ball

Correct answer: D

Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.

3. Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?

• A. Starting an IV
• B. Applying oxygen
• C. Obtaining blood gases
• D. Medicating the client for pain

Correct answer: B

Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.

4. What are appropriate nursing strategies to assist a client in maintaining a sense of self?

• A. Addressing the client by their first name when interacting with them
• B. Treating the client with dignity
• C. Explaining procedures to the client regardless of their attentiveness
• D. Encouraging the use of personal items to foster a sense of identity

Correct answer: B

Rationale: Maintaining a sense of self is crucial for clients in healthcare settings. Treating the client with dignity is a fundamental nursing principle that helps preserve the client's self-worth and identity. Addressing the client by their first name when interacting with them is a way to show respect, but it alone may not significantly contribute to maintaining their sense of self. Explaining procedures to the client, regardless of their attentiveness, is essential for informed consent and autonomy, empowering them in their care. Encouraging the use of personal items can foster a sense of identity as these items often hold personal significance and emotional value for the client, thus supporting their sense of self; therefore, discouraging their use would be counterproductive in maintaining a client's sense of self.

5. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

• A. administer both medications simultaneously.
• B. give the medications sequentially, and flush well between them.
• C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
• D. start one medication now and begin the other medication in 2-4 hours.

Correct answer: B

Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent interaction. Choice C is incorrect because the nurse, not the physician or pharmacy, should determine the correct administration sequence. Consulting with the pharmacist is appropriate if uncertain. Choice D is incorrect because delaying the second medication by several hours can slow the treatment of the client's infection, as both antibiotics are needed promptly to address the infection effectively. Therefore, the correct action is to give the medications sequentially and flush well between them to prevent any potential interactions.

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