Nursing Elites

1. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

• A. 2 cups of soup
• B. 1 quart of water
• C. 8 oz of ice chips
• D. 6 oz of tea

Correct answer: C

Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.

2. 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. Tie the restraints to the side rails of the bed
• C. Secure the restraints to the bed frame
• D. Use a quick-release knot to tie the restraints

Correct answer: A

Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client’s wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.

3. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?

• A. “I will set my water heater at 130°F.”
• B. “Once my baby can sit up, they should be safe in the bathtub.”
• C. “I will place my baby on their stomach to sleep.”
• D. “Once my infant starts to push up, I will remove the mobile from over the crib.”

Correct answer: D

Rationale: The correct answer is D. Removing the mobile when the baby starts to push up prevents choking hazards as infants can reach and grab objects posing a risk of choking. Choice A is unsafe as setting the water heater at 130°F can scald a child. Choice B is incorrect because even when a baby can sit up, they still require close supervision in the bathtub. Choice C is unsafe as current guidelines recommend placing babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Therefore, choices A, B, and C are incorrect or unsafe practices for infant care.

4. A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?

• A. Tie the restraint with a quick-release knot.
• B. Use a slipknot to secure the restraint.
• C. Ensure the restraint is tightly secured.
• D. Attach the restraint to the bed frame.

Correct answer: A

Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.

5. A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client’s medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?

• A. Fairness
• B. Responsibility
• C. Risk-taking
• D. Creativity

Correct answer: B

Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.

Similar Questions