Nursing Elites

1. While changing the linen on the client's bed, what should the nurse do?

• A. Hold the linen away from their body and clothing.
• B. Fold the linen neatly before placing it in the laundry.
• C. Wear clean gloves while handling the linen.
• D. Place the linen directly on the floor until the new linen is in place.

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

2. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

• A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
• B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
• C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
• D. Before changing assignments, determine which staff members have fitted particulate filter masks

Correct answer: D

Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.

3. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

• A. Remove clocks from the client’s room
• B. Use full-length side rails on the client’s bed
• C. Check on the client frequently while they are in the restroom
• D. Encourage physical activity throughout the day to expend energy

Correct answer: D

Rationale: Encouraging physical activity throughout the day is an effective way to manage confusion in clients and reduce the need for restraints. Physical activity helps in expending energy, promoting circulation, and improving overall well-being. Removing clocks from the client’s room (choice A) may not directly address the issue of confusion or reduce the need for restraints. Using full-length side rails on the client’s bed (choice B) can actually increase the risk of entrapment and should be avoided. Checking on the client frequently while they are in the restroom (choice C) is important for monitoring safety but may not directly address the underlying issue of confusion and the need for restraints.

4. A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?

• A. Contact the hospital’s spiritual services.
• B. Ask what is making the client cry.
• C. Ensure no visitors or staff enter the room for a short time period.
• D. Turn on the television for a distraction.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to ensure no visitors or staff enter the room for a short time period. Respecting the client's wish for privacy during emotional moments is crucial for providing patient-centered care. Contacting spiritual services or asking about the reason for crying may intrude on the client's privacy and emotional space. Turning on the television for a distraction is not appropriate as it does not address the client's emotional needs or request for privacy.

5. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

• A. Using a cuff that is too small will result in an inaccurately high reading.
• B. Using a cuff that is too large will result in an inaccurately low reading.
• C. The regular size cuff is appropriate for all clients.
• D. You should use a cuff of any size as long as it fits.

Correct answer: A

Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.

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