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1. When a client who is in pain refuses to be repositioned, what should the nurse consider first in making a decision about what to do?
- A. Why a decision is needed.
- B. Who actually gets to make the decision?
- C. What are the alternatives?
- D. When a decision is needed.
Correct answer: A
Rationale: In this scenario, the nurse should first consider why a decision is needed. Understanding the underlying reason for the decision helps in selecting the best action to meet the desired goal. Who actually makes the decision is important but not the primary consideration. Exploring alternatives comes after determining the reason for the decision, who makes it, and when it is needed.
2. To best reduce the potential for risk, what type of atmosphere is needed to be developed?
- A. Nurse-focused
- B. Physician-focused
- C. Family-focused
- D. Patient-focused
Correct answer: D
Rationale: The correct answer is 'Patient-focused.' When aiming to reduce the potential for risk, it is essential to prioritize the needs and well-being of the patients. Creating a patient-focused atmosphere helps ensure that decisions and actions are made with the patients' best interests in mind. Choices A, B, and C are incorrect because while nurses, physicians, and families play essential roles in healthcare, when it comes to reducing risks, the primary focus should be on the patients themselves.
3. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrists before applying the restraints.
- B. Evaluate the client's circulation every 8 hours after application.
- C. Secure the restraint ties to the bed's side rails.
- D. Remove the restraints every 4 hours to evaluate the client's status.
Correct answer: C
Rationale: When applying wrist restraints, it is crucial to secure the restraint ties to the bed's side rails to ensure the client's safety and prevent injury. Padding the client's wrists (Choice A) is not a standard practice and may compromise the effectiveness of the restraints. Evaluating the client's circulation (Choice B) is important but should be done more frequently than every 8 hours to ensure prompt detection of any circulation issues. Removing the restraints every 4 hours (Choice D) is unnecessary and may increase the risk of injury or agitation in the client.
4. A nurse has just inserted a nasogastric (NG) tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?
- A. The client reports relief of nausea.
- B. The tube aspirate has a pH less than 5.
- C. Bowel sounds are present on auscultation.
- D. An x-ray shows the end of the tube above the pylorus.
Correct answer: A
Rationale: The correct answer is A: The client reports relief of nausea. When the NG tube is correctly placed in the stomach, it can help alleviate feelings of nausea and discomfort. Choice B, a tube aspirate pH less than 5, is incorrect as it indicates gastric placement, not necessarily correct placement. Choice C, bowel sounds on auscultation, and Choice D, visualization of the tube on an x-ray above the pylorus, do not confirm correct NG tube placement; therefore, they are incorrect.
5. Which of the following is a skill emotionally intelligent leaders must develop?
- A. Encourage constructive criticism.
- B. Work to complete all assigned tasks on his or her own.
- C. Minimize one�s own emotions, instead of seeking to understand the emotions of others.
- D. Encourage others to work efficiently and independently.
Correct answer: A
Rationale: Encourage constructive criticism.
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