Nursing Elites

1. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

• A. Straps with quick-release buckles attached to bed side rails.
• B. Attempts to distract the patient with television are unsuccessful.
• C. Bilateral radial pulses present, 2+, hands warm to the touch.
• D. Released from restraints, active range-of-motion exercises completed.

Correct answer: C

Rationale: The correct answer is C because documenting bilateral radial pulses being present, 2+, and hands warm to the touch is crucial when caring for a patient in restraints. This information helps in monitoring circulation and assessing the patient's well-being. Choices A, B, and D are incorrect because they do not provide essential information related to the patient's safety and well-being while in restraints.

2. While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Temperature

Correct answer: C

Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.

3. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

• A. Lock beds and wheelchairs when not in use
• B. Administer a sedative at bedtime
• C. Provide information about home safety checks
• D. Teach balance and strengthening exercises

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

4. A nurse manager assigns a nursing assistant a task outside of their role. What should the nursing assistant do?

• A. Follow the manager's directive
• B. Report the task to the charge nurse
• C. Refuse to perform the task
• D. Perform the task and document later

Correct answer: B

Rationale: If a nurse manager assigns a nursing assistant a task that is outside of their role, the nursing assistant should report the task to the charge nurse. This is important because the charge nurse can provide guidance on whether the task is appropriate for the nursing assistant to perform. Choice A is incorrect because blindly following a directive that is outside of the nursing assistant's scope could lead to negative consequences. Choice C might not be the best course of action initially, as it's important to seek clarification first. Choice D is also not the best option because performing a task outside of one's role without proper authorization can pose risks to both the patient and the nursing assistant.

5. Which action by the nurse demonstrates effective infection control measures?

• A. Perform hand hygiene before and after patient contact.
• B. Wear gloves when administering medications.
• C. Dispose of used equipment in designated containers.
• D. Wear a mask when interacting with the patient.

Correct answer: A

Rationale: The correct answer is A: Perform hand hygiene before and after patient contact. Effective hand hygiene is a fundamental infection control measure that helps prevent the spread of pathogens. Wearing gloves when administering medications (choice B) is important for protecting both the patient and the nurse but is not a direct demonstration of infection control. Disposing of used equipment in designated containers (choice C) is more related to proper waste management than infection control. Wearing a mask when interacting with the patient (choice D) is essential in certain situations, but hand hygiene is a more universal and critical practice for infection control.

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