Nursing Elites

1. While caring for Mrs. Thomas, you see a notation on the nursing care plan that states 'ambulate at least 10 yards qid'. This patient will be assisted with ambulation at which of the following times?

• A. 10:00 AM
• B. 10 am and 2 pm
• C. 10 am and 2 pm
• D. 10 am, 2 pm, 6 pm, and 10 pm

Correct answer: D

Rationale: The correct answer is to assist the patient with ambulation at 10 am, 2 pm, 6 pm, and 10 pm as qid stands for four times per day. This schedule is commonly followed in healthcare facilities to ensure regular ambulation and exercise for the patient. Choices A, B, and C do not cover all the specified times for ambulation as indicated by the qid notation on the care plan.

2. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

• A. Vest restraints should be used because they are the least restrictive type.
• B. Restraints should be used for 48 hours in non-psychiatric patients.
• C. Restraints should be applied to prevent wandering behavior.
• D. Alternative measures must be attempted first.

Correct answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

3. The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:

• A. Lymphatic System
• B. Digestive System
• C. Urinary System
• D. Respiratory System

Correct answer: A

Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.

4. What term is used to refer to generalized wasting of body tissues and malnutrition?

• A. Entropion
• B. Confabulation
• C. Induration
• D. Cachexia

Correct answer: D

Rationale: Cachexia is the correct term used to describe the generalized wasting of body tissues, ill health, and malnutrition associated with some chronic diseases. It involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers and other complications due to malnutrition and poor health. Entropion refers to an eyelid condition, confabulation is a memory disturbance, and induration is the abnormal hardening of a part of the body.

5. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)

• A. Eliminate the reservoir
• B. Block the portal of exit from the reservoir
• C. Block the portal of entry into the host
• D. Decrease the susceptibility of the host

Correct answer: B

Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.

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