Nursing Elites

1. When is removal of the restraints by the nurse appropriate?

• A. When medication that has been administered has taken effect
• B. When no acts of aggression are observed in the hour following the release of two extremity restraints
• C. When the nurse explores with the client the reasons for the angry and aggressive behavior
• D. When the client apologizes and tells the nurse that it will never happen again

Correct answer: B

Rationale: The correct answer is B. The nurse can safely remove restraints once no aggressive behavior is observed after releasing two extremity restraints for an hour. Choice A is incorrect because the removal of restraints should be based on the client's behavior rather than just the effect of medication. Choice C is incorrect as exploring reasons for aggressive behavior should be done before or during the intervention, not as a condition for removing restraints. Choice D is incorrect since an apology from the client does not guarantee a change in behavior or indicate that it is safe to remove the restraints.

2. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?

• A. Drowsy but responsive when her name is called
• B. SaO2 94%
• C. Respiratory rate 8/min
• D. Pain level of 6 on a scale from 0 to 10

Correct answer: C

Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.

3. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?

• A. Choosing a fresh pear would be a good snack option
• B. I should make refried beans for supper
• C. Selecting white rice as a side dish is a good choice
• D. Opting for bran cereal would be a good breakfast choice

Correct answer: C

Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.

4. A healthcare professional is reviewing the medical record of a client who received their medications 1 hour ago. The client reports chest pain. This can be an adverse effect of what medication?

• A. Digoxin
• B. Albuterol
• C. Lisinopril
• D. Metoprolol

Correct answer: B

Rationale: The correct answer is B, Albuterol. Albuterol can cause chest pain as a side effect due to its beta-agonist effects, which can lead to chest discomfort. Digoxin (choice A) is not typically associated with causing chest pain. Lisinopril (choice C) and Metoprolol (choice D) are not known to commonly cause chest pain as a side effect.

5. Which action by a nurse demonstrates effective communication with a patient?

• A. Providing the patient with written information about their care.
• B. Maintaining eye contact and listening actively to the patient.
• C. Using medical jargon to explain the patient's condition.
• D. Speaking with the patient in a hurried manner to save time.

Correct answer: B

Rationale: Maintaining eye contact and actively listening to the patient is crucial in effective communication as it helps build rapport, shows empathy, and ensures that the patient feels heard and understood. Providing written information can be helpful, but the direct interaction is essential for effective communication. Using medical jargon may confuse the patient instead of clarifying their condition. Speaking hurriedly can make the patient feel rushed and not valued, hindering effective communication.

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