Nursing Elites

1. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.

2. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

• A. Cleanse the foot with soap and water and apply an antibiotic ointment
• B. Provide teaching about the need for a tetanus booster within the next 72 hours.
• C. Have the mother check the child's temperature every 4 hours for the next 24 hours
• D. Transfer the child to the emergency department to receive a gamma globulin injection

Correct answer: A

Rationale: The correct first action for the nurse to implement is to cleanse the foot with soap and water and apply an antibiotic ointment to prevent infection. In cases of puncture wounds like stepping on a rusty nail, the immediate concern is to reduce the risk of infection. Providing teaching about the need for a tetanus booster within the next 72 hours is important as well, but it should come after the wound is cleansed. Checking the child's temperature and transferring to the emergency department for a gamma globulin injection are not the immediate priorities in this scenario.

3. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding is most concerning?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Increased abdominal girth

Correct answer: C

Rationale: In a client with cirrhosis presenting with jaundice and ascites, yellowing of the skin (icterus) is the most concerning assessment finding. This indicates significant liver dysfunction and a high level of bilirubin in the blood. Yellowing of the skin suggests a severe impairment of the liver's ability to process bilirubin, which can lead to serious complications. Peripheral edema and increased abdominal girth are common manifestations of cirrhosis but are not as acutely concerning as skin yellowing. Confusion and altered mental status are also critical findings in cirrhosis, indicating hepatic encephalopathy, but skin yellowing is more closely associated with the severity of liver dysfunction in this scenario.

4. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?

• A. Encourage the UAP to remain in the client's room until the procedure is completed.
• B. Explain that the hand rub can be completed in less than 2 minutes.
• C. Inform the UAP that handwashing helps to promote better asepsis.
• D. Determine why the UAP was not wearing gloves in the client's room.

Correct answer: B

Rationale: The correct answer is B. Explaining that hand rubs can be effective with less time allows the UAP to perform the procedure more efficiently while maintaining asepsis. Choice A is incorrect because the UAP does not need to remain in the client's room until the procedure is completed. Choice C is incorrect as the UAP was using an alcohol-based gel hand cleaner, not handwashing. Choice D is incorrect as the scenario does not mention any issue with glove usage, so it is not relevant to the situation at hand.

5. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor. What instruction should the nurse include in the medication teaching plan?

• A. Increase intake of potassium-rich foods
• B. Report increased bruising or bleeding
• C. Stop medication if a cough develops
• D. Limit intake of leafy green vegetables

Correct answer: B

Rationale: The correct answer is B: 'Report increased bruising or bleeding.' Enalapril, an ACE inhibitor, can lead to thrombocytopenia, a condition characterized by a low platelet count, which increases the risk of bruising and bleeding. Instructing the client to report any signs of increased bruising or bleeding is crucial for monitoring and managing this potential side effect. Choices A, C, and D are incorrect: A - Increasing potassium-rich foods is not directly related to the side effects of enalapril. C - Developing a cough is a common side effect of ACE inhibitors, but it does not warrant stopping the medication unless advised by a healthcare provider. D - Limiting intake of leafy green vegetables is not necessary with enalapril unless specifically instructed by a healthcare provider for individual reasons.

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