Nursing Elites

1. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?

• A. Remove the client's restraint every 4 hours.
• B. Document the client's condition every 15 minutes.
• C. Attach the restraint to the bed's side rails.
• D. Request a PRN restraint prescription for clients who are aggressive.

Correct answer: B

Rationale: The correct answer is B. When updating protocols for the use of belt restraints, it is essential to document the client's condition every 15 minutes. This frequent documentation helps ensure the client's safety and allows for timely assessment of the need for continued restraint use. Choice A is incorrect because restraints should be removed and reassessed more frequently than every 4 hours. Choice C is incorrect as restraints should not be attached to the bed's side rails due to entrapment risks. Choice D is also incorrect as restraints should not be used as needed (PRN) but rather based on a specific prescription and assessment indicating the need for restraint use.

2. A nurse is assessing a client who is in active labor. The FHR baseline has been 100/min for the past 15 minutes. What condition should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: In this scenario, the FHR baseline of 100/min for the past 15 minutes indicates fetal bradycardia, which can be caused by maternal hypoglycemia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. Maternal fever (Choice A) typically presents with tachycardia in the fetus rather than bradycardia. Fetal anemia (Choice B) is more likely to manifest as tachycardia due to compensation for decreased oxygen delivery. Chorioamnionitis (Choice D) may lead to fetal tachycardia as a sign of fetal distress, not bradycardia.

3. What is the priority nursing intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, ensuring adequate oxygenation is the priority. Administering oxygen helps improve oxygen levels, which is crucial for the patient's well-being. Repositioning the patient, administering bronchodilators, or giving IV fluids are important interventions in certain situations, but when a patient is in respiratory distress, providing oxygen takes precedence over other actions.

4. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

• A. Social relationships with peers.
• B. Plans for attending school while pregnant.
• C. Eligibility for Medicaid.
• D. Understanding of infant care.

Correct answer: D

Rationale: The correct answer is D: Understanding of infant care. When assessing a pregnant adolescent, the priority is to ensure that she has the necessary knowledge and skills to care for her newborn. This assessment is crucial in promoting the health and well-being of both the adolescent mother and her baby. Option A, social relationships with peers, though important, is not the priority during this assessment. Option B, plans for attending school while pregnant, is also important but does not take precedence over ensuring the adolescent's understanding of infant care. Option C, eligibility for Medicaid, is important for accessing healthcare services but is not the priority assessment in this scenario.

5. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella roster. Which of the following information should the nurse include?

• A. Children who have varicella are contagious until vesicles are crusted
• B. Children who have varicella should receive the herpes zoster vaccination
• C. Children who have varicella should be placed in droplet precautions
• D. Children who have varicella are contagious 4 days before the first vesicle eruption

Correct answer: A

Rationale: The correct answer is A. Children with varicella are contagious until the vesicles crust over, which is important for preventing transmission. Choice B is incorrect as varicella and herpes zoster are caused by different viruses, so the varicella vaccine is given to prevent varicella, not herpes zoster. Choice C is incorrect because varicella is primarily spread through respiratory secretions, so airborne precautions are recommended, not droplet precautions. Choice D is incorrect as children with varicella are contagious even before the first vesicle eruption, not just 4 days before.

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