Nursing Elites

1. Which of these devices is considered a protective device, rather than a restraint?

• A. A mitten on the hands to prevent scratching
• B. A mitten on the hands to prevent the person from pulling their IV out
• C. A side rail to prevent the patient from falling
• D. A soft wrist restraint to prevent the patient from pulling their IV tubing

Correct answer: A

Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.

2. Is it true that Hepatitis C virus (HCV) can be spread through hugging, sneezing, coughing, sharing eating utensils, and other forms of casual contact?

• A. True
• B. False
• C.
• D.

Correct answer: B

Rationale: False. HCV is not spread through casual contact such as hugging, sneezing, or sharing eating utensils. The correct modes of transmission for HCV include direct contact with human blood through blood transfusions, improperly sterilized needles and syringes, needle sharing, or occasionally through sexual contact. Therefore, the statement is false, making 'False' the correct answer. Choices A, C, and D are incorrect as they do not accurately reflect the mode of transmission of HCV.

3. What might be signaled when a client tells the nurse to 'pray for me' and entrusts her wedding ring to the nurse?

• A. Anxiety
• B. Suicidal ideation
• C. Major depression
• D. Hopelessness

Correct answer: B

Rationale: The client entrusting the wedding ring and asking the nurse to pray for them can be indicative of suicidal ideation. This behavior suggests a deep level of distress and hopelessness, potentially leading to suicidal thoughts or actions. While anxiety is a common emotion, the act of entrusting personal items and making requests like praying for them go beyond typical anxiety symptoms. Major depression can be associated with suicidal ideation, but the specific actions described in this scenario point more towards suicidal thoughts. Hopelessness, while related to suicidal ideation, is a broader concept that does not capture the specific cues given by the client in this scenario, making it a less accurate choice.

4. A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?

• A. Bring the IV kit and quickly start an IV
• B. Assess his breathing and provide oxygen, if necessary
• C. Administer medication to control chest pain
• D. Talk with his wife and find out why she is crying

Correct answer: B

Rationale: In the above scenario, the first action of the nurse should be to assess the client's airway and breathing. It is crucial to address respiratory status first, as the client appears to be experiencing difficulty breathing. Providing oxygen if necessary can help support oxygenation and alleviate potential respiratory distress. Administering medication for chest pain or starting an IV can come after ensuring adequate oxygenation. Talking with the client's wife, though important for emotional support, is not the priority when the client's respiratory status needs to be assessed and managed promptly.

5. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?

• A. External light sources may cause falsely high oximetry values
• B. A bright light in the client's face may cause a low pulse oximetry
• C. External light sources may cause falsely low oximetry values
• D. The client needs a dark and quiet room to recover and maintain proper oxygenation

Correct answer: A

Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.

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