Nursing Elites

1. What is the nurse's responsibility when managing a physically assaultive client?

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control
• D. Clear the area of other clients

Correct answer: C

Rationale: The correct answer is C: Restore the client's self-control. When managing a physically assaultive client, the nurse's responsibility is to help the client regain control over their actions and emotions. This is crucial in preventing harm to themselves and others. Restricting the client to the room (Choice A) may escalate the situation and is not a therapeutic approach. Placing the client under one-to-one supervision (Choice B) is important for safety but does not address the root cause of the behavior. Clearing the area of other clients (Choice D) is necessary for safety but does not directly address the client's self-control. Therefore, the priority in managing an assaultive client is to focus on restoring their self-control.

2. A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?

• A. Take this medication in the morning.
• B. Avoid drinking grapefruit juice.
• C. Increase your intake of leafy green vegetables.
• D. Monitor your pulse daily while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Avoid drinking grapefruit juice.' Grapefruit juice can increase the risk of toxicity when taken with simvastatin. Instructing the client to avoid grapefruit juice helps prevent this interaction. Choice A is incorrect because the timing of medication administration for simvastatin is usually in the evening. Choice C is unrelated to simvastatin therapy. Choice D is not necessary for monitoring while taking simvastatin.

3. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?

• A. Wear sterile gloves when applying a new dressing
• B. Cleanse the wound from the center outwards
• C. Keep the wound dry between dressing changes
• D. Apply an antimicrobial ointment to the wound

Correct answer: B

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.

4. What are the signs of an acute myocardial infarction?

• A. Chest pain radiating to the arm and shortness of breath
• B. Nausea, vomiting, and high fever
• C. Headache, confusion, and low blood pressure
• D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

5. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

• A. Change the appliance daily
• B. Clean the stoma once a day
• C. Avoid changing the appliance for a week
• D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

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