Nursing Elites

1. A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:

• A. Linens from the client's bed should be double-bagged.
• B. Meals should be served on washable dishes.
• C. Extensive isolation rarely causes psychological problems.
• D. Paper trays and plastic utensils do not prevent disease transmission.

Correct answer: A

Rationale: Isolation techniques are used to prevent or limit the spread of infection. Special handling of articles and linens soiled by any body fluid is essential. Linens should be placed in impervious bags before being removed from the client's bedside to prevent exposure of personnel and contamination of the environment. Double-bagging is required if the outside of the bag becomes contaminated. This practice ensures that potentially infectious materials are properly contained and disposed of. Choices B, C, and D are incorrect because the focus in this scenario is on proper handling and disposal of soiled linens to prevent the spread of infection, not on serving meals, psychological effects of isolation, or the use of paper trays and plastic utensils.

2. In which situation is the nurse upholding the ethical principle of fidelity?

• A. Providing complete information regarding treatment options to a client with newly diagnosed cancer
• B. Allowing a client to decide when to receive daily hygiene care
• C. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion
• D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

Correct answer: D

Rationale: Fidelity is the ethical principle of keeping promises made to clients, families, and other healthcare professionals. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan exemplifies fidelity. By advocating for the client's preferences and ensuring their requests are addressed, the nurse demonstrates a commitment to fulfilling promises made to the client. Allowing a client to decide when to receive daily hygiene care relates to respecting autonomy, not fidelity. Inserting a 19-gauge intravenous catheter into a client needing a blood transfusion aligns with beneficence, as it involves taking action to provide necessary treatment. Providing complete information to a client with newly diagnosed cancer about treatment options reflects justice, promoting fairness and equity in healthcare by offering equal access to information and treatment choices.

3. What is the appropriate intervention for a client who is restrained?

• A. Remove the restraints and provide skin care every hour.
• B. Document the condition of the client's skin every 3 hours.
• C. Assess the restraint every 30 minutes
• D. Tie the restraint to the side rails.

Correct answer: C

Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.

4. Which of the following is true of advanced directives?

• A. They should be appropriately documented in the client's chart.
• B. They are only applicable if the client has a terminal illness.
• C. They are required if the client is unconscious.
• D. They are non-legal requests.

Correct answer: A

Rationale: The correct answer is that advanced directives should be appropriately documented in the client's chart. Advanced directives are legal requests regarding a client's healthcare that come into effect under specific circumstances, regardless of the severity of their illness or level of consciousness. Choice B is incorrect because advanced directives can cover various healthcare decisions, not just terminal illnesses. Choice C is incorrect as advanced directives can be established and documented while the client is conscious, not only if they are unconscious. Choice D is incorrect because advanced directives are indeed legal requests, not non-legal requests.

5. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

• A. "I should make sure he gets plenty of rest."?
• B. "I should get him a medical alert bracelet."?
• C. "I should lay him on his back during a seizure."?
• D. "I should loosen his clothing during a seizure."?

Correct answer: C

Rationale: The correct answer is "I should lay him on his back during a seizure."? This statement indicates a need for further teaching because a client having a seizure should be turned to the side to prevent aspiration of secretions. Choices A, B, and D are correct. Getting plenty of rest helps in managing seizures, having a medical alert bracelet informs others about the condition in case of emergency, and loosening clothing during a seizure ensures better air circulation and prevents injury. These actions demonstrate adequate understanding of the teaching provided.

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