Nursing Elites

1. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

• A. The institution's restraints/seclusion policies
• B. The patient's competence
• C. The patient's voluntary/involuntary status
• D. The patient's nursing care plan

Correct answer: C

Rationale: The correct answer is C because the patient's voluntary or involuntary status should not impact the nurse's actions when using restraints. The use of restraints should be based on the patient's behavior and the need to ensure their safety and the safety of others. Choices A, B, and D are important factors that should influence the nurse's actions. The institution's restraints/seclusion policies provide guidelines on the appropriate use of restraints, the patient's competence helps determine their understanding and ability to control their behavior, and the patient's nursing care plan guides the overall care provided, including the use of restraints if necessary.

2. What are the key nursing considerations for a patient with a central venous catheter?

• A. Maintain sterility during dressing changes
• B. Change the dressing weekly
• C. Monitor blood pressure and fluid balance
• D. Monitor the catheter site for infection

Correct answer: A

Rationale: The correct answer is A: Maintain sterility during dressing changes. It is crucial to maintain sterility during dressing changes for patients with central venous catheters to prevent infections. Changing the dressing weekly (Choice B) is not frequent enough to prevent infections effectively. Monitoring blood pressure and fluid balance (Choice C) is important for overall patient care but not specific to central venous catheter management. While monitoring the catheter site for infection (Choice D) is important, the key consideration is to prevent infections through proper sterile techniques during dressing changes.

3. A client diagnosed with gout is receiving dietary instruction from a nurse. What dietary advice should be provided?

• A. Limit intake of fresh fruits and uncooked vegetables
• B. Limit intake of red meat and shellfish
• C. Limit intake of dairy products
• D. Increase intake of leafy greens

Correct answer: B

Rationale: The correct answer is to limit the intake of red meat and shellfish. These foods are high in purines, which can increase uric acid levels and trigger gout flare-ups. Fresh fruits, uncooked vegetables, dairy products, and leafy greens are generally not associated with exacerbating gout symptoms and do not need to be significantly restricted in the diet of someone with gout.

4. A client is using a metered-dose inhaler (MDI) for asthma management. Which of the following actions by the client indicates an understanding of the teaching?

• A. Inhale rapidly through the mouth after pressing down on the inhaler
• B. Exhale completely before pressing down on the inhaler
• C. Hold your breath for 5-10 seconds after inhaling
• D. Inhale slowly while pressing down on the inhaler

Correct answer: C

Rationale: The correct answer is to hold your breath for 5-10 seconds after inhaling when using a metered-dose inhaler (MDI) for asthma management. This action ensures proper medication absorption in the lungs. Inhaling rapidly (choice A) may cause the medication to impact the mouth/throat rather than the lungs. Exhaling completely before inhalation (choice B) does not optimize medication delivery. Inhaling slowly (choice D) may not allow the medication to reach the lungs effectively.

5. What are the signs and symptoms of fluid overload?

• A. Edema, shortness of breath, weight gain
• B. High blood pressure and jugular venous distention
• C. Low blood pressure and cyanosis
• D. Tachycardia and dizziness

Correct answer: A

Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.

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