Nursing Elites

1. Why is client and family communication and education concerning restraints essential?

• A. confuses both groups further
• B. helps with coping and stress levels
• C. encourages cooperation with the client and family
• D. puts the responsibility on the client and family, not the nurse

Correct answer: C

Rationale: Client and family communication and education concerning restraints are essential to encourage cooperation. When the client and family understand the purpose and expected benefits of restraints, they are more likely to cooperate. This understanding can help prevent well-meaning family members from releasing restraints due to confusion or lack of information. Therefore, choice C is correct. Choices A, B, and D are incorrect because confusing both groups further, helping with coping and stress levels, and shifting responsibility to the client and family are not the primary goals of communication and education concerning restraints.

2. While on the wound care team, the nurse notices that a fellow nurse opens extra colloid dressings that are often thrown away when they are not needed. What should the nurse do?

• A. Do nothing, as it is not impacting client care.
• B. Discuss with the colleague the concern about wasting supplies.
• C. Tell the charge nurse to stop ordering these dressings.
• D. Remove the colloid dressings from the shelf so that the nurse will find other supplies to use.

Correct answer: B

Rationale: The correct answer is to discuss with the colleague the concern about wasting supplies. By addressing this issue, the nurse can promote cost-effective care within the unit. While it may not directly impact client care, the wastage of supplies affects the unit's supply cost, making choice A incorrect. Choice C is incorrect as it assumes the charge nurse is solely responsible for the ordering process and overlooks the opportunity for direct communication between colleagues. Choice D is incorrect as it involves taking matters into one's own hands rather than addressing the issue through communication and collaboration.

3. An LPN is caring for a primarily bedridden client. Which finding should be of least concern?

• A. swollen feet
• B. brown discoloration above the ankles
• C. leg pain
• D. capillary refill time of 3 seconds on the big toe

Correct answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.

4. A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?

• A. Heart rate
• B. Peripheral pulses
• C. Blood pressure (BP)
• D. Radial pulse rate

Correct answer: B

Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.

5. To remove hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
• B. Grasp the lens with a gentle pinching motion
• C. Don sterile gloves before attempting the procedure
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

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