Nursing Elites

1. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

• A. Wear cotton clothing to avoid static electricity.
• B. Avoid using any electrical appliances.
• C. Keep the oxygen tank away from heat sources.
• D. Use only a specific type of nasal cannula.

Correct answer: A

Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.

2. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action:

• A. May result in charges of unlawful seclusion and restraint
• B. Leaves the nurse vulnerable to charges of assault and battery
• C. Was appropriate given the client's history of violence
• D. Was necessary to maintain the therapeutic milieu of the unit

Correct answer: A

Rationale: Placing a client in seclusion without proper justification and documentation can lead to charges of unlawful seclusion and restraint, regardless of the client's compliance. This legal issue arises from the potential violation of the client's rights and must be avoided. Choice B is incorrect as the situation does not involve assault and battery. Choice C is incorrect as past violence alone does not justify seclusion without immediate risk. Choice D is incorrect as seclusion should be used based on individual risk and necessity, not solely for maintaining the therapeutic milieu.

3. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

• A. Delegates assessment of lung sounds to nursing assistive personnel
• B. Becomes solely responsible for modifying activities of daily living
• C. Consults physical therapy for strengthening exercises in the extremities
• D. Involves respiratory therapy for altered breathing from severe anxiety levels

Correct answer: C

Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.

4. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

• A. Not offering a backrub to a patient with fractured ribs
• B. Not offering to wash the hair of a patient with neck trauma
• C. Turning off the television while giving a backrub to the patient
• D. Turning the patient's head with neck injury to the side when giving oral care

Correct answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

5. A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor to determine the effectiveness of this medication?

• A. Serum creatinine
• B. Hemoglobin
• C. Blood urea nitrogen (BUN)
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Hemoglobin. Epoetin alfa (Epogen) is a medication commonly used in clients with chronic kidney disease to stimulate red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of epoetin alfa therapy. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and indicate if the medication is successfully treating anemia associated with chronic kidney disease. Option A, serum creatinine, is a marker of kidney function, not the primary indicator of epoetin alfa effectiveness. Option C, blood urea nitrogen (BUN), is a measure of kidney function and hydration status. Option D, platelet count, assesses clotting ability and is unrelated to monitoring the effectiveness of epoetin alfa in treating anemia in chronic kidney disease.

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