Nursing Elites

1. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

• A. Placing a belt restraint on a school-age child who has seizures.
• B. Securing wrist restraints to the bed rails for an adolescent.
• C. Applying elbow immobilizers to an infant receiving cleft lip injury.
• D. Keeping the side rails of a toddler's crib elevated.

Correct answer: D

Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.

2. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?

• A. Substernal retractions
• B. Hematuria
• C. Temperature of 37.9°C (100.2°F)
• D. Sneezing

Correct answer: A

Rationale: Substernal retractions indicate respiratory distress in a sickle-cell client, which can be a sign of acute chest syndrome. This condition is a serious complication of sickle-cell anemia characterized by chest pain, fever, cough, and shortness of breath. Reporting this symptom promptly is crucial for timely intervention. Choice B, hematuria, is not typically associated with acute chest syndrome but may indicate other issues such as a urinary tract infection. Choice C, a temperature of 37.9°C (100.2°F), is slightly elevated but not a specific indicator of acute chest syndrome. Choice D, sneezing, is not a typical symptom of acute chest syndrome and would not warrant immediate reporting to the provider in this context.

3. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

• A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
• B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
• C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
• D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.

Correct answer: C

Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.

4. A nurse is assessing a client with a history of post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

• A. Dependence on family and friends
• B. Loss of interest in usual activities
• C. Ritualistic behavior
• D. Passive-aggressive behavior

Correct answer: B

Rationale: The correct answer is B: Loss of interest in usual activities. Clients with PTSD often exhibit symptoms such as numbing, which can manifest as a loss of interest in activities they once enjoyed. Choice A, dependence on family and friends, is more indicative of seeking support rather than a direct symptom of PTSD. Choice C, ritualistic behavior, is more commonly associated with conditions like obsessive-compulsive disorder. Choice D, passive-aggressive behavior, is not a typical finding in clients with PTSD.

5. A client with osteoporosis should be encouraged to perform which of the following interventions as part of the plan of care?

• A. Encourage the client to increase calcium intake.
• B. Apply heat to the affected joints to reduce stiffness.
• C. Encourage weight-bearing exercises to prevent bone loss.
• D. Limit fluid intake to prevent swelling.

Correct answer: C

Rationale: The correct answer is to encourage weight-bearing exercises to prevent bone loss in clients with osteoporosis. Weight-bearing exercises help to strengthen bones and reduce the risk of fractures. Increasing calcium intake (Choice A) is important for bone health but is not the priority intervention for preventing bone loss in osteoporosis. Applying heat to affected joints (Choice B) may help with stiffness but does not address the underlying bone loss in osteoporosis. Limiting fluid intake (Choice D) is not relevant to managing osteoporosis and preventing bone loss.

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