Nursing Elites

1. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

• A. Determining the need for restraints
• B. Obtaining an order for a restraint
• C. Assessing the patient's orientation
• D. Applying the restraint

Correct answer: D

Rationale: The correct answer is applying the restraint (Choice D). Nursing assistive personnel can be delegated the task of applying restraints under the supervision and direction of a nurse. Determining the need for restraints (Choice A) and obtaining an order for a restraint (Choice B) involve clinical judgment and assessment, which are responsibilities of the nurse. Assessing the patient's orientation (Choice C) also requires a level of assessment that should be performed by a nurse.

2. A client who had a stroke is complaining of left-side weakness. What should the nurse prioritize?

• A. Initiate physical therapy immediately.
• B. Contact the physical therapy team.
• C. Reassess the client after administering pain medication.
• D. Start treatment immediately without consulting anyone.

Correct answer: B

Rationale: The correct answer is to contact the physical therapy team. When a client who had a stroke presents with left-side weakness, the nurse should prioritize coordinating with the physical therapy team rather than immediately initiating physical therapy. The initial step should involve assessing the client's condition and involving the appropriate healthcare team for a comprehensive care plan. Administering pain medication or starting treatment without consulting others can delay or hinder the appropriate care needed for the client's recovery.

3. A nurse is completing an assessment of a recently widowed older adult client. He states he is unable to drive and is afraid to cook on the stove. Which of the following community resources should the nurse recommend?

• A. Hospice care
• B. Meals on Wheels
• C. Home health services
• D. American Association of Retired Persons

Correct answer: B

Rationale: The correct answer is B: Meals on Wheels. Meals on Wheels is a community resource that provides food for older adults who are unable to cook for themselves, promoting independence and ensuring proper nutrition. Hospice care (choice A) focuses on providing comfort and support for individuals with life-limiting illnesses; it is not primarily aimed at providing meals. Home health services (choice C) typically involve skilled nursing care and therapy services provided in the home setting, rather than meal delivery. The American Association of Retired Persons (choice D) offers advocacy, support, and resources for older adults but does not directly address the specific needs mentioned in the client's situation.

4. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?

• A. Drowsy but responsive when her name is called
• B. SaO2 94%
• C. Respiratory rate 8/min
• D. Pain level of 6 on a scale from 0 to 10

Correct answer: C

Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.

5. A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?

• A. Amphotericin B
• B. Amoxicillin-clavulanate
• C. Erythromycin
• D. Gentamicin

Correct answer: B

Rationale: Amoxicillin-clavulanate is related to penicillin, and a cross-sensitivity could occur, so the provider should be consulted.

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