Nursing Elites

1. After unsuccessful alternatives, a patient requires restraints. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care?

• A. The health care provider writes the type and location of the restraint.
• B. The health care provider renews orders for restraints every 24 hours.
• C. The health care provider performs a face-to-face assessment prior to the order.
• D. The health care provider orders restraints PRN (as needed).

Correct answer: A

Rationale: In the context of restraining a patient, it is crucial for the health care provider to specify the type and location of the restraint in the order to ensure the safety and well-being of the patient. This information helps guide the nursing staff in the safe application of restraints. Renewing orders every 24 hours ensures that the need for restraints is continually assessed, promoting patient safety. Performing a face-to-face assessment before ordering restraints allows for a thorough evaluation of the patient's condition and the necessity of using restraints. Ordering restraints PRN (as needed) is not appropriate for safe care as it lacks specificity and may lead to inconsistent application and monitoring.

2. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

• A. Demonstrate how to use the spirometer
• B. Set a realistic postoperative goal
• C. Determine the reasons why the client is refusing
• D. Request that a respiratory therapist discuss the technique

Correct answer: C

Rationale: The priority action for the nurse is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or issues, the nurse can address them effectively, provide education or support, and encourage the client to comply with the necessary postoperative care. This approach fosters a patient-centered care environment. Demonstrating how to use the spirometer (Choice A) may be important but is not the priority at this moment. Setting a realistic postoperative goal (Choice B) is relevant but not as immediate as understanding the client's refusal. Requesting a respiratory therapist (Choice D) can be considered later if needed, but the nurse's initial focus should be on understanding the client's perspective.

3. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?

• A. Apply a dry, sterile dressing to the wound.
• B. Use sterile saline to clean the wound.
• C. Apply a warm compress to promote circulation.
• D. Keep the wound open to air for faster healing.

Correct answer: B

Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.

4. 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.

5. A school nurse is developing a teaching plan about testicular cancer for a group of clients. Which of the following information should the nurse include in the teaching?

• A. Perform a testicular self-examination weekly.
• B. Do not palpate the epididymis when performing a testicular self-examination.
• C. Expect testicles to be uniform in consistency when performing a testicular self-examination.
• D. Perform a testicular self-examination after a cool shower.

Correct answer: C

Rationale: The correct answer is C because testicles should be uniform in consistency when performing a self-exam, and any lumps or abnormalities should be reported. Choice A is incorrect as testicular self-examinations should be performed monthly, not weekly. Choice B is incorrect because the epididymis should be included in the examination. Choice D is incorrect because a warm shower helps relax the scrotum, making the exam easier to perform.

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