Nursing Elites

1. Which of the following statements describes the purpose of client restraint?

• A. Restraints are a nursing measure used to maintain client control.
• B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
• C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
• D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct answer: Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.

Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.

2. Which of the following tests is commonly performed on newborns with jaundice?

• A. blood urea nitrogen
• B. magnesium
• C. bilirubin
• D. prolactin

Correct answer: bilirubin

Rationale: The correct answer is C: bilirubin. A high bilirubin level is found in newborns with hepatic immaturity, leading to jaundice. Testing bilirubin levels is crucial in diagnosing and monitoring jaundice in newborns. Choices A, B, and D (blood urea nitrogen, magnesium, and prolactin) are not commonly performed tests for evaluating jaundice in newborns. Blood urea nitrogen is a measure of kidney function, magnesium levels are usually checked in metabolic disorders, and prolactin is a hormone related to lactation, none of which are directly relevant to assessing jaundice in newborns.

3. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

• A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
• B. Assisting a client who is getting up to ambulate for the first time after surgery
• C. Providing oral care to an unconscious client who requires oral care
• D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: Providing oral care to an unconscious client who requires oral care

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.

4. When documenting in the client’s record, what type of information should be recorded?

• A. educated predictions of outcomes
• B. personal opinions
• C. objective information
• D. subjective information

Correct answer: C

Rationale: When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care. Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition. Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.

5. What are the hazards of improper splinting?

• A. Aggravation of a bone or joint injury
• B. Reduced distal circulation
• C. Delay in transporting a client with a life-threatening injury
• D. All of the above

Correct answer: D

Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.

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