Nursing Elites

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

• A. Place a belt restraint on a school-age child who has seizures.
• B. Secure wrist restraints to the bed rails for an adolescent.
• C. Apply elbow immobilizers to an infant with a cleft lip injury.
• D. Keep the side rails of a toddler's crib elevated.

Correct answer: D

Rationale: The correct use of restraints is crucial to ensure patient safety. Keeping the side rails of a toddler's crib elevated is a safe practice as it prevents falls and provides a level of protection without directly restraining the child. Placing a belt restraint on a child with seizures (Choice A) is inappropriate as it may restrict movement and cause harm during a seizure. Securing wrist restraints to bed rails for an adolescent (Choice B) is not recommended as it can lead to injuries and compromise circulation. Applying elbow immobilizers to an infant with a cleft lip injury (Choice C) is also incorrect as it does not address the issue of restraint and is not a standard practice in this situation.

2. A nurse is caring for a client who has pneumonia and is receiving oxygen therapy. Which of the following findings indicates the need for suctioning?

• A. Increased respiratory rate.
• B. Oxygen saturation 96%.
• C. Clear lung sounds.
• D. Productive cough.

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate. An increased respiratory rate suggests the client is having difficulty clearing secretions and may require suctioning. Oxygen saturation of 96% is within the normal range and indicates adequate oxygenation. Clear lung sounds suggest good air entry without the need for suctioning. A productive cough, although a symptom of pneumonia, does not directly indicate the need for suctioning.

3. A healthcare professional is assessing a client who has a new prescription for digoxin. Which of the following findings is the priority for the healthcare professional to report to the provider?

• A. Heart rate of 58/min
• B. Weight gain of 1 kg (2.2 lb) in 24 hours
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: The correct answer is A. A heart rate of 58/min is indicative of bradycardia, a potential sign of digoxin toxicity, which should be reported immediately. While weight gain, respiratory rate, and temperature are important parameters to monitor, they are not as critical as identifying bradycardia in a client taking digoxin.

4. A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?

• A. Take this medication in the evening before bed.
• B. Take this medication on an empty stomach.
• C. Take this medication with a full glass of milk.
• D. Take this medication with an antacid if you experience indigestion.

Correct answer: B

Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.

5. A client on glucocorticoid therapy is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I have my eyes examined annually.
• B. I take a calcium vitamin supplement daily.
• C. I limit my intake of foods with potassium.
• D. I consistently take my medication between 8 and 9 each evening.

Correct answer: B

Rationale: The correct answer is B. Taking a calcium supplement daily is crucial for clients on glucocorticoid therapy to prevent osteoporosis, a common side effect of long-term use. Choice A is unrelated to glucocorticoid therapy. Choice C, limiting potassium intake, is not necessary for clients on glucocorticoids. Choice D, taking medication consistently in the evening, is important but does not specifically address the side effects of glucocorticoid therapy.

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