Nursing Elites

1. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

2. A 3-year-old child diagnosed with celiac disease attends a daycare center. Which of the following would be an appropriate snack?

• A. Cheese crackers
• B. Peanut butter sandwich
• C. Potato chips
• D. Vanilla cookies

Correct answer: C

Rationale: The correct answer is potato chips. As a child with celiac disease needs to avoid gluten, potato chips are a suitable snack choice as they are typically gluten-free. Cheese crackers (Choice A) and vanilla cookies (Choice D) contain gluten, which should be avoided by individuals with celiac disease. While peanut butter sandwiches (Choice B) could be gluten-free depending on the bread used, it is not the best choice as cross-contamination is a concern in shared environments like daycare centers.

3. When providing a bath, in which order will the nurse clean the body, beginning with the first area?

• A. Face
• B. Eyes
• C. Perineum
• D. Back and buttocks

Correct answer: B

Rationale: The correct sequence for giving a bath starts with cleaning the eyes, followed by the face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and finally the buttocks/anus. Therefore, the first area to be cleaned during a bath is the eyes. Choices A, C, and D are incorrect as per the standard procedure for providing a bath.

4. A healthcare professional is providing teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the professional include?

• A. Urticaria
• B. Ptosis
• C. Nausea
• D. Hematuria

Correct answer: A

Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. It presents as raised, red, itchy welts on the skin. Ptosis is drooping of the upper eyelid and is not typically associated with allergic reactions. Nausea is a gastrointestinal symptom that can occur with various conditions but is not specific to allergic reactions. Hematuria, which is the presence of blood in the urine, is not a typical manifestation of an allergic reaction.

5. An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.

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