Nursing Elites

1. Nursing care plans contain which of the following?

• A. nursing diagnoses
• B. medical diagnoses.
• C. MD orders.
• D. intake and output forms

Correct answer: A

Rationale: Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.

2. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

• A. Vest restraints should be used because they are the least restrictive type.
• B. Restraints should be used for 48 hours in non-psychiatric patients.
• C. Restraints should be applied to prevent wandering behavior.
• D. Alternative measures must be attempted first.

Correct answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

3. Which technique is correct when assessing the radial pulse of a patient?

• A. Palpate for 1 minute if the rhythm is irregular.
• B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
• C. Palpate for 2 full minutes to detect any variation in amplitude.
• D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.

Correct answer: A

Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.

4. A physician has ordered that a client must be placed in a high Fowler's position. How does the nurse position this client?

• A. The client is placed face-down
• B. The client lies on his back with his head lower than his feet
• C. The client lies on his back with the knees drawn up toward the chest
• D. The client is sitting with the backrest at a 90-degree angle

Correct answer: D

Rationale: A high Fowler's position is a modification of the semi-Fowler's position, in which the client is seated with arms resting at the sides or in the lap. The high Fowler's position requires that the client's head and upper chest are elevated, and the backrest is at a 90-degree angle. This position supports breathing and appropriate chest wall movement, making it easier for the client to breathe. Choices A, B, and C are incorrect because a high Fowler's position involves the client being in a sitting position with the backrest at a 90-degree angle, not being face-down, lying with the head lower than the feet, or lying on the back with knees drawn up towards the chest.

5. All of the following factors may contribute to client falls EXCEPT:

• A. Contact dermatitis
• B. Urinary frequency
• C. Decreased visual acuity
• D. Confusion

Correct answer: A

Rationale: Client falls can result from various factors, both intrinsic and extrinsic. Intrinsic factors include health conditions like urinary frequency, which increases the need for bathroom visits, decreased visual acuity, and confusion. These factors can directly contribute to an increased risk of falls. However, contact dermatitis does not directly lead to falls. Contact dermatitis is a skin condition caused by contact with irritants or allergens and does not inherently predispose individuals to falling. Therefore, among the given options, contact dermatitis is the only factor that is not directly associated with an increased risk of falls.

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