Nursing Elites

1. What is the appropriate intervention for a client who is restrained?

• A. Remove the restraints and provide skin care every hour.
• B. Document the condition of the client’s skin every 3 hours.
• C. Assess the restraint every 30 minutes
• D. Tie the restraint to the side rails.

Correct answer: Assess the restraint every 30 minutes

Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.

2. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

• A. “I should raise him to a sitting position.”
• B. “I should check for a fecal impaction.”
• C. “I should look for a kink in the urinary catheter tubing.”
• D. “I should observe whether symptoms worsen.”

Correct answer: “I should observe whether symptoms worsen.”

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

3. To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?

• A. flexion, extension, hyperextension
• B. flexion, extension, abduction, adduction
• C. external rotation, internal rotation
• D. extension, flexion, inversion, eversion

Correct answer: extension, flexion, inversion, eversion

Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.

4. During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?

• A. Ask the television crew to interview the individuals attending the program individually.
• B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
• C. Explain to the television crew that videotaping is not allowed.
• D. Allow the television crew to videotape the program.

Correct answer: Explain to the television crew that videotaping is not allowed.

Rationale: Privacy is a client’s right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client’s privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.

5. After undergoing gastric resection, the client is informed by the nurse that which of the following meals is most likely to cause rapid emptying of the stomach?

• A. a high-protein meal
• B. a high-fat meal
• C. a large meal regardless of nutrient content
• D. a high-carbohydrate meal

Correct answer: a high-carbohydrate meal

Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. On the other hand, high-fat and high-protein meals tend to delay gastric emptying. A large meal, regardless of nutrient content, can also delay gastric emptying due to the increased volume of food that needs to be processed.

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