Nursing Elites

1. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

• A. 240 cc
• B. 120 cc
• C. 8 cc
• D. 0 cc because Italian ice is not a fluid

Correct answer: A

Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.

2. An adult's blood pressure reads 40/20. You place the patient in a Trendelenberg position before rechecking the blood pressure. What actions will you take to position the patient correctly?

• A. lower the head of the bed and raise the foot of the bed
• B. raise the head of the bed up to about 60 to 75 degrees
• C. raise the head of the bed up to about 75 to 90 degrees
• D. raise the siderails and place the bed in the high position

Correct answer: A

Rationale: In a Trendelenberg position, used for low blood pressure, the correct action is to lower the head of the bed and raise the foot of the bed. This positioning facilitates the return of blood to the heart and helps increase blood pressure. Option B, raising the head of the bed to 60 to 75 degrees, is incorrect as it is not the Trendelenberg position. Option C, raising the head of the bed to 75 to 90 degrees, is incorrect as it does not align with the Trendelenberg position. Option D, raising the siderails and placing the bed in the high position, is incorrect as it does not address the specific positioning required for the Trendelenberg position.

3. When caring for a patient with latex allergy, the healthcare provider creates a latex-safe environment by doing which of the following?

• A. Carefully cleaning the wall-mounted blood pressure device before using it.
• B. Donning latex gloves outside the room to limit powder dispersal.
• C. Using a latex-free pharmacy protocol.
• D. Placing the patient in a semi-private room.

Correct answer: C

Rationale: Creating a latex-safe environment for a patient with latex allergy is crucial to prevent allergic reactions. Using a latex-free pharmacy protocol is essential as it ensures that medications and supplies provided to the patient are free of latex components. Cleaning a wall-mounted blood pressure device may not be sufficient as the device itself may contain latex parts that can trigger an allergic reaction. Donning latex gloves, even outside the room, is not recommended as powder dispersal can cause issues; only non-latex gloves should be used in a latex-safe environment. Placing the patient in a semi-private room does not directly address the need to eliminate latex exposure from medical supplies and equipment, which is better achieved through a latex-free pharmacy protocol.

4. 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.

5. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.

• A. Hopelessness
• B. Power
• C. Interrupted sleep pattern
• D. Disturbed self-esteem

Correct answer: A

Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.

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