Nursing Elites

1. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?

• A. Provide cognitive-behavioral therapy
• B. Offer frequent orientation and reassurance
• C. Administer a sedative to improve memory recall
• D. Refer the client to a neurologist for further evaluation

Correct answer: B

Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.

2. A nurse notices that a colleague has an odor of alcohol while on duty. What is the most appropriate action?

• A. Speak to the colleague in private.
• B. Report the behavior to the nurse manager immediately.
• C. Confront the colleague directly on the floor.
• D. Do nothing and document the situation.

Correct answer: B

Rationale: Reporting the behavior to the nurse manager immediately is the most appropriate action when a nurse suspects a colleague of being impaired while on duty. This is crucial to ensure patient safety and maintain a professional and safe work environment. Speaking to the colleague in private may not address the issue effectively and could potentially put patients at risk if the colleague is indeed impaired. Confronting the colleague directly on the floor may lead to a confrontation and is not the most professional way to handle the situation. Doing nothing and documenting the situation without taking immediate action can jeopardize patient safety and is not an appropriate response when substance use is suspected.

3. After unsuccessful alternatives, a patient requires restraints. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care?

• A. The health care provider writes the type and location of the restraint.
• B. The health care provider renews orders for restraints every 24 hours.
• C. The health care provider performs a face-to-face assessment prior to the order.
• D. The health care provider orders restraints PRN (as needed).

Correct answer: A

Rationale: In the context of restraining a patient, it is crucial for the health care provider to specify the type and location of the restraint in the order to ensure the safety and well-being of the patient. This information helps guide the nursing staff in the safe application of restraints. Renewing orders every 24 hours ensures that the need for restraints is continually assessed, promoting patient safety. Performing a face-to-face assessment before ordering restraints allows for a thorough evaluation of the patient's condition and the necessity of using restraints. Ordering restraints PRN (as needed) is not appropriate for safe care as it lacks specificity and may lead to inconsistent application and monitoring.

4. Which goal is most appropriate for a patient who has had a total hip replacement?

• A. The nurse will assist the patient in ambulating in the hall 2 times a day.
• B. The patient will walk 100 feet using a walker by the time of discharge.
• C. The patient will ambulate briskly on the treadmill by the time of discharge.
• D. The patient will ambulate independently by the time of discharge.

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.

5. A community health nurse is providing an educational session on childhood poisoning at a local school. What should the nurse advise as the first action if poisoning occurs?

• A. Call the poison control center
• B. Bring the child to the emergency department (ED)
• C. Induce vomiting
• D. Call an ambulance

Correct answer: A

Rationale: In the event of poisoning, the recommended first action is to call the poison control center. Poison control specialists can provide immediate guidance on how to manage the situation effectively. Bringing the child to the emergency department (Choice B) may be necessary depending on the severity of the poisoning, but contacting poison control first is crucial for appropriate and timely intervention. Inducing vomiting (Choice C) is not advised in all cases of poisoning and should only be done under the guidance of healthcare professionals. Calling an ambulance (Choice D) may be necessary in some severe cases, but the initial step should be to contact poison control for expert advice.

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