Nursing Elites

1. Which of the following is an example of restorative care?

• A. A nurse teaches a new mother how to breastfeed her infant
• B. A nurse helps a client with developing a bladder-retraining program
• C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
• D. A nurse contacts the family of a client to tell them he will be out of surgery soon

Correct answer: B

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.

2. Which of the following nursing interventions is appropriate for a client suffering from a fever?

• A. Avoid withholding food from the client
• B. Increase the client's fluid intake
• C. Provide oxygen
• D. All answers are correct

Correct answer: B

Rationale: The appropriate nursing intervention for a client suffering from a fever is to increase the client's fluid intake. A fever can elevate the body's metabolism, leading to increased breathing and heart workload. This can result in fluid loss due to heightened respiration and sweating. Moreover, the augmented heart workload may necessitate more oxygen to maintain tissue perfusion. Providing oxygen and increasing fluid intake help meet the body's heightened demands during a fever. Withholding food from the client is inappropriate as proper nutrition is crucial for recovery, and providing oxygen alone may not address the fluid and metabolic demands associated with fever. Therefore, the correct choice is to increase the client's fluid intake.

3. While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?

• A. Abdominal respirations
• B. Inspiratory grunt
• C. Nasal flaring
• D. Cyanosis

Correct answer: A

Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.

4. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:

• A. Rest, Ice, Compression, Elevation
• B. Radiology, Ice, Compression, Elevation
• C. Rest, Ice, Cast, Elevation
• D. Radiology, Ice, Cast, Elevation

Correct answer: A

Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.

5. A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:

• A. Avoid eating red meat for 3 days before the test
• B. Collect the stool sample from the toilet after having a bowel movement
• C. The stool does not need to be kept in a container with preservative
• D. A small part of the stool from two areas will be tested using a smear

Correct answer: B

Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.

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