Nursing Elites

1. A client is on bed rest. Which of the following interventions should the nurse plan to implement?

• A. Encourage the client to perform antiembolic exercises every 2 hours.
• B. Instruct the client to cough and deep breathe every 4 hours.
• C. Restrict the client’s fluid intake.
• D. Reposition the client every 4 hours.

Correct answer: A

Rationale: To prevent complications associated with prolonged bed rest, encouraging the client to perform antiembolic exercises every 2 hours is essential. These exercises help promote circulation and prevent blood clots. Instructing the client to cough and deep breathe every 4 hours is beneficial for respiratory function, but it is not as critical as antiembolic exercises. Repositioning the client every 4 hours helps prevent pressure ulcers and maintain skin integrity. Restricting fluid intake is not recommended, as hydration is important for overall health and well-being, especially for clients on bed rest.

2. While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

• A. Remove the restraints one at a time
• B. Secure the restraints tightly to prevent movement
• C. Check the restraints every hour
• D. Use leather restraints for additional security

Correct answer: A

Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.

3. While measuring a client’s oral temperature using an electronic thermometer, what action should the nurse take?

• A. Assist the client with oral hygiene before taking the temperature.
• B. Inquire whether the client has smoked in the last 30 minutes.
• C. Connect the red tip probe to the thermometer unit.
• D. Position the probe tip against the client’s buccal mucosa.

Correct answer: B

Rationale: The correct action for the nurse to take when measuring a client’s oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.

4. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?

• A. A client who has a new diagnosis of adrenal insufficiency
• B. A client who has heart failure
• C. A client who is receiving treatment for diabetic ketoacidosis
• D. A client who has abdominal ascites

Correct answer: B

Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.

5. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

• A. Troponin level of 0.5 ng/mL
• B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
• C. Serum potassium of 4.5 mEq/L
• D. Blood glucose of 180 mg/dL

Correct answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

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