Nursing Elites

1. Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?

• A. Nurse will check client q1h for the presence of chest pain
• B. Client has a nervous, tense personality and is likely to overreact
• C. Client states he will notify the nurse if chest pain returns
• D. Client understands how to use the call button and the telephone

Correct answer: C

Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.

2. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

• A. Observe the PICC line site for inflammation.
• B. Encourage increasing fluid intake.
• C. Monitor blood pressure regularly.
• D. Assess skin turgor for dehydration.

Correct answer: A

Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.

3. The mother of a school-age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse’s best response?

• A. When all live lice are eliminated by the treatment
• B. Two weeks after the last treatment
• C. As soon as the itching stops
• D. After the treatment kills all the live lice

Correct answer: D

Rationale: The correct answer is 'After the treatment kills all the live lice.' The child can return to school once all live lice are eliminated to prevent the spread of Pediculosis capitis. This is essential as live lice are highly contagious. Choices A, B, and C are incorrect. Waiting for the itching to stop or for an epidemic to subside does not ensure that all live lice are eradicated, which is crucial to prevent reinfestation and transmission.

4. A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin?

• A. Fetal heart tones located in the upper right quadrant
• B. Biophysical profile results showing oligohydramnios
• C. Regular contractions occurring every 10 minutes
• D. Sterile vaginal exam revealing 3 cm dilation

Correct answer: B

Rationale: Oligohydramnios (low amniotic fluid) is a significant concern before starting oxytocin and should be reported to ensure safe labor induction. This finding can indicate potential fetal compromise and requires immediate evaluation. Fetal heart tones located in a specific quadrant, regular contractions, and cervical dilation are common assessments during labor but are not as critical as oligohydramnios in this scenario.

5. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

• A. Ensure that the knot can be quickly released.
• B. Tie the knot with a double turn or square knot.
• C. Move the ties so the restraints are secured to the side rails.
• D. Ensure that the restraints are snug against the client's wrist.

Correct answer: A

Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.

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