Nursing Elites

1. A client has restraints on each extremity. Which of the following assessments should the nurse perform first?

• A. Peripheral pulses
• B. Comfort level
• C. Elimination needs
• D. Skin integrity

Correct answer: A

Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.

2. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

• A. Remove clocks from the client’s room
• B. Use full-length side rails on the client’s bed
• C. Check on the client frequently while they are in the restroom
• D. Encourage physical activity throughout the day to expend energy

Correct answer: D

Rationale: Encouraging physical activity throughout the day is an effective way to manage confusion in clients and reduce the need for restraints. Physical activity helps in expending energy, promoting circulation, and improving overall well-being. Removing clocks from the client’s room (choice A) may not directly address the issue of confusion or reduce the need for restraints. Using full-length side rails on the client’s bed (choice B) can actually increase the risk of entrapment and should be avoided. Checking on the client frequently while they are in the restroom (choice C) is important for monitoring safety but may not directly address the underlying issue of confusion and the need for restraints.

3. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

• A. Bag bath
• B. Sponge bath
• C. Partial bed bath
• D. Complete bed bath

Correct answer: C

Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.

4. During a skin assessment, a client expresses concern about skin cancer due to a lesion on the anterior thigh. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

• A. An uneven shape
• B. A uniformly colored lesion
• C. A lesion that is small and flat
• D. A lesion that is less than 1 cm in diameter

Correct answer: A

Rationale: An uneven shape of a lesion is a common characteristic of malignant skin lesions. Asymmetric or irregularly shaped lesions are concerning for skin cancer and should be reported promptly for further evaluation and management. Choice B, a uniformly colored lesion, is more indicative of a benign lesion as malignant lesions often exhibit variations in color. Choice C, a lesion that is small and flat, does not necessarily indicate malignancy by itself. Choice D, a lesion that is less than 1 cm in diameter, is more suggestive of a benign lesion, as malignant lesions are typically larger in size.

5. A healthcare professional is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the healthcare professional take?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
• B. Recheck the pulse at the same site after 5 minutes.
• C. Measure the client’s blood pressure.
• D. Record the irregularity and continue with other vital signs.

Correct answer: A

Rationale: When an irregular pulse is detected, it is essential to count the apical pulse rate for a full minute to accurately determine the rhythm. This ensures a comprehensive assessment and helps in identifying any potential issues or abnormalities. Rechecking the pulse at the same site after 5 minutes (Choice B) may not provide an immediate understanding of the irregularity. Measuring the client's blood pressure (Choice C) is important but not directly related to addressing the irregular pulse. Recording the irregularity and continuing with other vital signs (Choice D) may overlook a potentially serious cardiac issue that requires immediate attention.

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