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 nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?

• A. Administer the medication without further assessment.
• B. Check the tube placement before administering any medication.
• C. Administer the medication in liquid form only.
• D. Administer half the dosage as a precaution.

Correct answer: B

Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.

3. A nurse manager is asked to select clients for early discharge from the unit following a mass casualty event. Which of the following clients should the nurse manager recommend?

• A. A client awaiting a screening colonoscopy later that day
• B. A client whose discharge was cancelled the prior day because they developed respiratory distress
• C. A client who is 6 hr postoperative following an open cholecystectomy
• D. A client who is prescribed gastric lavage treatments to treat acute aspirin toxicity

Correct answer: A

Rationale: The nurse manager should recommend the client awaiting a screening colonoscopy later that day for early discharge following a mass casualty event. This client is stable and not in immediate need of hospital care. Choices B, C, and D involve clients who require ongoing monitoring and care due to recent developments or treatments, making them unsuitable for early discharge during a mass casualty event.

4. An occupational health nurse in a factory is planning interventions to reduce environmental stressors for employees. Which of the following interventions should the nurse use to affect physical agents in the environment?

• A. Teach workers to choose personal strategies to cope with work stress
• B. Limit the amount of time workers spend in temperatures over 43.3°C (110°F)
• C. Provide ear plugs for use at workstations throughout the factory
• D. Obtain dosimeters for employees to wear when using new machinery that emits radiation

Correct answer: B

Rationale: Limiting exposure to extreme temperatures is important to protect workers from heat-related illnesses.

5. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?

• A. A client who has a right femur fracture with no weight-bearing on the affected leg
• B. A client who has bilateral leg braces due to paralysis of the lower extremities
• C. A client who has bilateral knee replacements with partial weight-bearing on both legs
• D. A client who is able to bear full weight on both lower extremities

Correct answer: A

Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.

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