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 client with delirium?

• A. Administer sedative medication to calm the client
• B. Identify any reversible causes of delirium
• C. Limit environmental stimulation to reduce anxiety
• D. Administer antipsychotic medication to control behavior

Correct answer: B

Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose level of 120 mg/dL
• B. White blood cell count of 8,000/mm³
• C. Temperature of 37.2°C (99°F)
• D. Daily weight increase of 0.45 kg (1 lb)

Correct answer: D

Rationale: The correct answer is D. A sudden weight increase may indicate fluid retention, a complication of TPN therapy that should be reported. Options A, B, and C are within normal ranges and do not directly relate to TPN therapy complications. A blood glucose level of 120 mg/dL is normal, a white blood cell count of 8,000/mm³ is within the normal range, and a temperature of 37.2°C (99°F) is also normal.

4. A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?

• A. How severe is your pain on a scale of 1 to 10?
• B. Where is your pain located?
• C. What medication are you taking for the pain?
• D. When did the pain start?

Correct answer: B

Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.

5. A client with peripheral arterial disease (PAD) is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Apply lotion between the toes
• B. Wear shoes that fit properly
• C. Walk barefoot at home
• D. Apply ice to the feet daily

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes that fit properly.' In peripheral arterial disease (PAD), it is crucial to wear shoes that fit well to prevent foot injuries. Choice A is incorrect because applying lotion between the toes can increase the risk of infection. Choice C is incorrect since walking barefoot at home can lead to injuries, especially in individuals with PAD. Choice D is incorrect as applying ice to the feet daily can further reduce blood flow to the extremities, worsening the condition in PAD.

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