Nursing Elites

1. When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?

• A. The presence and location of any pressure ulcers.
• B. Measures already taken to maintain client safety.
• C. Any special mattresses on the client’s bed.
• D. Current vital signs and oxygen saturation.

Correct answer: B

Rationale: The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.

2. While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?

• A. Cardiopulmonary resuscitation with uterine tilt
• B. The Heimlich maneuver using chest thrusts
• C. The Heimlich maneuver using subdiaphragmatic thrusts
• D. Call 911 immediately then begin cardiopulmonary resuscitation

Correct answer: C

Rationale: The correct action for the nurse to take when a pregnant woman is choking and unable to speak is to perform the Heimlich maneuver using subdiaphragmatic thrusts. This technique is recommended for a pregnant woman to prevent harm to the fetus. Option A, cardiopulmonary resuscitation with uterine tilt, is not indicated for a choking episode. Option B, the Heimlich maneuver using chest thrusts, can potentially harm the gravid uterus. Option D, calling 911 immediately before providing assistance, can lead to a delay in addressing the immediate choking emergency.

3. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?

• A. Increase the intake of salty foods
• B. Administer NaCl supplements
• C. Restrict oral fluid intake
• D. Hold the client's loop diuretic

Correct answer: C

Rationale: In the scenario described, the client presents with signs of fluid overload and hyponatremia. Restricting oral fluid intake is the appropriate intervention to manage fluid overload and correct hyponatremia. Increasing the intake of salty foods (Choice A) and administering NaCl supplements (Choice B) would exacerbate the sodium imbalance. Holding the client's loop diuretic (Choice D) is not directly related to addressing the fluid overload and hyponatremia.

4. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

5. A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

• A. Assess the client’s need for pain medication
• B. Document the impending signs of death
• C. Inform the nurse manager of the client’s status
• D. Communicate the client’s status to the chaplain

Correct answer: A

Rationale: Assessing the client’s need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.

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