Nursing Elites

1. A client with a history of falls is being admitted to the unit. What intervention should the nurse implement first?

• A. Increase the client's medication to ensure they don't fall.
• B. Use bed alarms to monitor the client's movements.
• C. Encourage the client to use a walker for mobility.
• D. Assign the client to a nursing assistant for supervision.

Correct answer: B

Rationale: The correct answer is B: 'Use bed alarms to monitor the client's movements.' When a client with a history of falls is admitted, the nurse's initial intervention should focus on fall prevention measures. Using bed alarms to monitor the client's movements can help alert the healthcare team if the client attempts to get out of bed and reduce the risk of falls. Choice A is incorrect because increasing medication should not be the first intervention as it may not address the underlying causes of falls and can have adverse effects. Choice C may be appropriate but is not the priority over implementing safety measures like bed alarms. Choice D is incorrect as assigning the client to a nursing assistant for supervision alone may not be as effective as utilizing bed alarms for continuous monitoring.

2. What is an expected finding during the assessment of a client transitioning into a new role?

• A. The client's ability to express feelings of guilt
• B. Presence of suicidal or homicidal ideation
• C. Changes in coping skills over the past few weeks
• D. Client's involvement in community activities

Correct answer: B

Rationale: During a client's transition into a new role, the presence of suicidal or homicidal ideation should be assessed due to the increased risk associated with significant life changes. This finding could indicate a need for immediate intervention. While assessing the client's ability to express feelings of guilt is important, it may not be the most critical aspect during this specific assessment. Changes in coping skills over time are relevant but might not be the primary focus during a role transition assessment. The client's involvement in community activities, although beneficial for social support, is not directly related to the immediate concerns of assessing a client transitioning into a new role.

3. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?

• A. Crush all medications and administer them all at once.
• B. Flush the NG tube before and after each medication.
• C. Administer only liquid forms of medications.
• D. Skip flushing the tube entirely.

Correct answer: B

Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.

4. A nurse is preparing to administer a medication that requires a peak and trough level. What is the nurse's priority action?

• A. Administer the medication before the peak level is obtained.
• B. Withhold the medication until the trough level is obtained.
• C. Administer the medication based on the previous trough level.
• D. Ensure that the medication is administered within 2 hours of the peak level.

Correct answer: B

Rationale: The nurse's priority action should be to withhold the medication until the trough level is obtained. This is crucial to ensure accurate dosing based on the patient's levels. Administering the medication before the peak level is obtained (choice A) can lead to incorrect dosing. Administering the medication based on the previous trough level (choice C) may not reflect the current levels accurately. Ensuring that the medication is administered within 2 hours of the peak level (choice D) is not necessary for obtaining accurate peak and trough levels.

5. A client with renal calculi is admitted. What is the priority nursing intervention?

• A. Monitor urinary output every shift.
• B. Administer pain medication as ordered.
• C. Strain all urine for stones.
• D. Increase fluid intake to flush the urinary tract.

Correct answer: C

Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.

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