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 healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?

• A. Fever of 101°F.
• B. Blood pressure of 140/90 mmHg.
• C. Heart rate of 95 beats per minute.
• D. Crackles heard in the lung bases.

Correct answer: D

Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.

3. While providing care to a group of patients, which patient should the nurse see first?

• A. A patient after knee surgery who needs range of motion exercises
• B. A patient on bed rest who has renal calculi and needs to go to the bathroom
• C. A bedridden patient who has a reddened area on the buttocks who needs to be turned
• D. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea

Correct answer: D

Rationale: The nurse should see the patient with a hip replacement experiencing chest pain and dyspnea first because these symptoms could indicate a pulmonary embolism, which is a life-threatening condition requiring immediate attention. The other patients also need care, but urgent assessment and intervention are crucial in the case of potential pulmonary embolism to prevent serious complications or death.

4. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

• A. Monitor the patient's blood pressure regularly.
• B. Change the CVC dressing every 72 hours.
• C. Flush the CVC with normal saline every shift.
• D. Avoid using the CVC for blood draws.

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

5. When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?

• A. Proceed with the surgery and document the refusal.
• B. Ask the patient for permission to secure the jewelry safely.
• C. Tape the jewelry to the patient's body during surgery.
• D. Tell the patient they must remove the jewelry for safety reasons.

Correct answer: B

Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.

Similar Questions