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. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

• A. High workload
• B. Limited knowledge on the subject
• C. Poor lighting
• D. Limited space in the learning area

Correct answer: C

Rationale: The correct answer is C: 'Poor lighting.' External factors such as lighting can significantly impact the learning environment, making it difficult for participants to engage effectively. Poor lighting can strain the eyes, cause discomfort, and lead to decreased concentration. Choices A, B, and D are internal factors or issues that are not directly related to the learning environment. High workload, limited knowledge on the subject, and limited space in the learning area may affect learning differently but do not impede learning through external factors like poor lighting does.

3. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

4. A healthcare professional is managing a client with a wound infection. What is the priority action?

• A. Change the wound dressing every 12 hours
• B. Perform a wound culture before applying antibiotics
• C. Apply a wet-to-dry dressing to the wound
• D. Cleanse the wound with a solution of alcohol and water

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial to identify the specific pathogen causing the infection. This helps in selecting the most effective antibiotics for treatment. Changing the wound dressing, applying a wet-to-dry dressing, or cleansing the wound are important interventions but should follow the assessment and identification of the infecting organism through a wound culture to guide appropriate treatment.

5. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

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