Nursing Elites

1. A client with Alzheimer’s disease is becoming increasingly confused. What action should the nurse take first?

• A. Reorient the client to time and place.
• B. Monitor the client’s vital signs.
• C. Provide the client with calming activities to reduce confusion.
• D. Consult with the healthcare provider about adjusting the client’s medication.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client with Alzheimer’s disease is becoming increasingly confused is to monitor the client’s vital signs (Choice B). Increased confusion in Alzheimer’s disease patients may indicate underlying issues like infection, dehydration, or medication side effects. Monitoring vital signs is crucial in identifying any potential causes of the confusion. Choices A, C, and D are not the priority in this situation. Reorienting the client to time and place (Choice A) can be helpful but is not the first priority. Providing calming activities (Choice C) and consulting with the healthcare provider about medication adjustments (Choice D) may be necessary but should come after assessing the client's vital signs to rule out immediate physical causes of confusion.

2. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

• A. Heart murmur.
• B. Murmur.
• C. S3 sound.
• D. S4 sound.

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

3. Which client is at greatest risk for developing delirium?

• A. An adult client who cannot sleep due to pain.
• B. An older client who attempted suicide 1 month ago.
• C. A young adult taking antipsychotic medications twice daily.
• D. A middle-aged woman using supplemental oxygen.

Correct answer: B

Rationale: The correct answer is B. Older adults who have attempted suicide are at higher risk for developing delirium, especially in the context of underlying mental health conditions. Choice A is incorrect as sleep disturbances due to pain may lead to discomfort but not necessarily delirium. Choice C is incorrect as taking antipsychotic medications, if managed well, does not inherently increase the risk of delirium. Choice D is incorrect as using supplemental oxygen alone does not significantly increase the risk of developing delirium.

4. An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?

• A. Begin dopamine infusion at 2 mcg/kg/minute.
• B. Begin potassium chloride 10 mEq over 1 hour.
• C. Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes.
• D. Administer promethazine 25 mg IV push.

Correct answer: C

Rationale: In this scenario, the priority intervention is to give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes. The client's dark amber urine output indicates dehydration and hypovolemia, requiring rapid fluid resuscitation. Dopamine infusion, potassium chloride, and promethazine are not the initial interventions needed for a client with hypovolemic symptoms.

5. A client presents to the emergency room with an acute asthma attack. What is the nurse's priority intervention?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen at 2 liters per nasal cannula.
• C. Perform chest physiotherapy.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as prescribed. During an acute asthma attack, the priority is to open the airways quickly to help the client breathe more easily. Oxygen may be needed but bronchodilators take precedence as they directly target bronchoconstriction. Chest physiotherapy is not indicated in the acute phase of asthma and may exacerbate the condition. While emotional support is important, addressing the airway obstruction takes precedence in this situation.

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