Nursing Elites

1. A client requires seclusion to prevent harm to others on the unit. What action should the nurse take?

• A. Offer fluids every 2 hours.
• B. Document the client's behavior prior to being placed in seclusion.
• C. Discuss the client's inappropriate behavior prior to seclusion.
• D. Assess the client's behavior every hour.

Correct answer: B

Rationale: The correct answer is to document the client's behavior prior to being placed in seclusion. Documenting the behavior is crucial as it ensures that the decision to use seclusion is based on appropriate justifications and helps in monitoring the client's progress and response to the intervention. Offering fluids every 2 hours (Choice A) is not directly related to the need for seclusion. Discussing the client's behavior prior to seclusion (Choice C) may not be appropriate at the moment when immediate action is required to prevent harm. Assessing the client's behavior every hour (Choice D) is important but not as immediate as documenting the behavior prior to seclusion.

2. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?

• A. Sodium 144 mEq/L
• B. Potassium 5.2 mEq/L
• C. Bicarbonate 24 mEq/L
• D. Magnesium 1.9 mEq/L

Correct answer: B

Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.

3. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place a sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.

4. How should a healthcare professional care for a patient with a stage 2 pressure ulcer?

• A. Clean the area with normal saline
• B. Apply antibiotic ointment
• C. Use a hydrocolloid dressing
• D. Change the dressing daily

Correct answer: C

Rationale: Using a hydrocolloid dressing is the appropriate care for a stage 2 pressure ulcer because it provides a moist healing environment, promotes healing, and helps to prevent infection. Cleaning the area with normal saline (Choice A) is important but not the primary treatment for a stage 2 pressure ulcer. Applying antibiotic ointment (Choice B) may not be necessary unless there is a sign of infection. Changing the dressing daily (Choice D) may disrupt the healing process and is not recommended unless the dressing is soiled or compromised.

5. A client with a new diagnosis of celiac disease is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I can still have oatmeal for breakfast.
• B. I need to avoid foods that contain gluten.
• C. I can have rye toast with my eggs.
• D. I can continue to eat foods made from barley.

Correct answer: B

Rationale: The correct answer is B because clients with celiac disease should avoid gluten, which is found in foods like rye and barley. Choice A is incorrect because oatmeal may contain gluten unless specified gluten-free. Choice C is incorrect as rye contains gluten. Choice D is incorrect as barley contains gluten.

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