Nursing Elites

1. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?

• A. Administer PRN haloperidol (Haldol) to decrease the need to walk
• B. Assess the client's gait for steadiness
• C. Restrain the client in a geriatric chair
• D. Administer PRN lorazepam (Ativan) to provide sedation

Correct answer: B

Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.

2. What is the first step in managing a patient with a suspected pneumothorax?

• A. Insert a chest tube
• B. Monitor respiratory status
• C. Administer oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to insert a chest tube. In managing a patient with a suspected pneumothorax, the priority is to relieve the pressure from the pneumothorax by inserting a chest tube. Monitoring respiratory status (choice B) is important but comes after ensuring proper management of the pneumothorax. Administering oxygen (choice C) can help support oxygenation but does not address the underlying issue of pressure in the thoracic cavity. Calling for assistance (choice D) can be done concurrently with managing the pneumothorax, but the immediate intervention to address the pneumothorax itself is chest tube insertion.

3. A healthcare professional is reviewing the medical record of a client who is receiving furosemide. Which of the following laboratory values should the healthcare professional monitor while the client is taking this medication?

• A. Sodium
• B. Glucose
• C. Potassium
• D. Calcium

Correct answer: C

Rationale: The correct answer is C: Potassium. Furosemide is a diuretic that can cause potassium depletion due to increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Sodium (choice A) levels are not typically affected by furosemide. Glucose (choice B) monitoring is important with other medications like corticosteroids but is not directly related to furosemide use. Calcium (choice D) levels are not significantly impacted by furosemide.

4. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?

• A. White flour tortillas.
• B. Potato pancakes.
• C. Wheat crackers.
• D. Canned barley soup.

Correct answer: B

Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.

5. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, 'I am very upset and I want to be alone for a little while.' Which of the following responses should the nurse make?

• A. I see that you are feeling overwhelmed. I will come back when you are ready
• B. This is normal, and I will check on you later
• C. You are feeling frustrated. Let's talk about your concerns.
• D. You will feel better soon. Let me get you some water.

Correct answer: A

Rationale: Acknowledging the client's feelings and allowing them space demonstrates understanding and respect for their emotions.

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