Nursing Elites

1. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?

• A. Immediately do a complete head-to-toe neurological assessment.
• B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
• C. Place a blanket over the feet.
• D. Remove the restraint.

Correct answer: D

Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.

2. A nurse is teaching a client who has a new prescription for amoxicillin clavulanate to treat pharyngitis. Which statement indicates understanding?

• A. I will double my dose if I miss one
• B. I should take this medication on an empty stomach between meals
• C. I will take the medication until my sore throat goes away
• D. I will stop taking this medication if I develop itching

Correct answer: C

Rationale: The client should never double the dose if a dose is missed. This can lead to an overdose, which can cause serious adverse effects. Instead, the client should take the next dose as scheduled or consult the provider for guidance.

3. A patient with chronic kidney disease has been prescribed a low-protein diet. What is the nurse's priority intervention?

• A. Encourage the patient to eat small, frequent meals.
• B. Monitor the patient's intake and output.
• C. Educate the patient on the benefits of a low-protein diet.
• D. Monitor the patient's protein intake closely.

Correct answer: D

Rationale: The correct answer is to monitor the patient's protein intake closely. In patients with chronic kidney disease on a low-protein diet, monitoring protein intake is crucial to prevent complications such as malnutrition or inadequate nutrient intake. Encouraging small, frequent meals (Choice A) can be beneficial but is not the priority over monitoring protein intake. Monitoring intake and output (Choice B) is important but does not directly address the specific focus on protein intake. Educating the patient on the benefits of a low-protein diet (Choice C) is essential but not as immediate as monitoring the actual protein intake.

4. A nurse is caring for a client who is postoperative and has compression stockings. Which action should the nurse take?

• A. Check the stockings for wrinkles
• B. Apply the stockings while the client is sitting in a chair
• C. Measure the size of the client's foot
• D. Remove the stockings once each day

Correct answer: A

Rationale: The correct action for the nurse to take is to check the stockings for wrinkles. This is important to ensure that the stockings are applied correctly without any folds or wrinkles, which can hinder proper circulation and compression. Option B is incorrect because compression stockings should be applied with the client lying down, not sitting in a chair. Option C is unnecessary as the size of the client's foot is unlikely to change postoperatively. Option D is incorrect as compression stockings are usually worn continuously except for specific care needs.

5. What is the most appropriate action for a healthcare provider to take when a patient refuses a prescribed medication?

• A. Document the refusal and notify the healthcare provider.
• B. Administer the medication at a later time.
• C. Explain the importance of the medication and its effects.
• D. Respect the patient's right to refuse the medication.

Correct answer: D

Rationale: The correct answer is to respect the patient's right to refuse the medication. It is crucial to uphold the patient's autonomy and decision-making capacity when it comes to their treatment. Administering the medication later without the patient's consent (Choice B) disregards their autonomy and can lead to ethical issues. Documenting the refusal and notifying the healthcare provider (Choice A) is important for legal and continuity of care purposes but should come after respecting the patient's decision. While explaining the importance of the medication (Choice C) is valuable for promoting understanding and compliance, the immediate concern should be respecting the patient's refusal.

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