Nursing Elites

1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: D

Rationale: In a situation where a verbal prescription for restraints is obtained for a client experiencing acute mania, the nurse should document the client's condition every 15 minutes. This frequent documentation allows for accurate monitoring of the client's condition, ensuring safety and compliance. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is not directly related to the need for restraints in this scenario. Obtaining a prescription for restraint within 4 hours (Choice C) is not a priority when a verbal prescription is already obtained and immediate action is needed for the client's safety.

2. What is the initial step a nurse should take when irrigating a wound?

• A. Wear sterile gloves while removing the old dressing
• B. Cleanse the wound from the center outward
• C. Apply a warm compress to the wound
• D. Use a 20 mL syringe to irrigate the wound

Correct answer: B

Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.

3. What is the priority nursing intervention for a patient with chest pain?

• A. Administer nitroglycerin
• B. Assess pain level
• C. Monitor vital signs
• D. Provide oxygen therapy

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.

4. A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor daily fluid intake
• B. Monitor blood glucose levels
• C. Measure intake and output
• D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.

5. A client undergoing bariatric surgery is being taught about postoperative dietary changes by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will drink carbonated beverages after surgery
• B. I will eat large meals after surgery
• C. I will avoid consuming solid foods for several weeks
• D. I will avoid taking small sips of liquids

Correct answer: C

Rationale: The correct answer is C because avoiding solid foods after bariatric surgery is crucial to prevent complications and promote healing. Choice A is incorrect as carbonated beverages can cause discomfort and should be avoided. Choice B is incorrect as large meals are not suitable after bariatric surgery. Choice D is incorrect as taking small sips of liquids is encouraged to prevent dehydration and promote recovery.

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