Nursing Elites

1. A client with chronic kidney disease is experiencing pruritus. Which intervention should the nurse include in the plan of care?

• A. Administer antihistamines as prescribed.
• B. Apply moisturizing lotion to the skin.
• C. Use cool water for bathing.
• D. Encourage a high-protein diet.

Correct answer: A

Rationale: Correct. Administering antihistamines as prescribed is the appropriate intervention for a client with chronic kidney disease experiencing pruritus. Antihistamines can help reduce pruritus by blocking histamine receptors, which are often prescribed for such clients. Choice B, applying moisturizing lotion, may help with dry skin but will not directly address pruritus. Choice C, using cool water for bathing, may provide some relief but does not target the underlying cause of pruritus. Choice D, encouraging a high-protein diet, is not directly related to managing pruritus in chronic kidney disease.

2. A home health nurse is reviewing the laboratory results for several clients with heart failure. Which client finding would the nurse report to the health care provider immediately?

• A. Total cholesterol 190
• B. Glycosylated hemoglobin of 7%
• C. B-type natriuretic peptide 550 pg/ml (more than 100 is concerning)
• D. Potassium 3.7

Correct answer: C

Rationale: An elevated B-type natriuretic peptide level indicates worsening heart failure, requiring immediate attention. This biomarker reflects the severity of heart failure and helps guide treatment decisions. Total cholesterol and glycosylated hemoglobin are important for assessing cardiovascular risk and diabetes management but are not indicative of acute heart failure exacerbation. A potassium level of 3.7 falls within the normal range and does not suggest an immediate concern in the context of heart failure.

3. What is the most important information for a nurse to obtain when an older female client expresses not deserving to eat due to lack of money?

• A. Client's thoughts about wanting to hurt herself
• B. Medication history for antipsychotic agents
• C. Availability of family members to provide meals
• D. Community resources to provide financial aid

Correct answer: A

Rationale: The correct answer is A: Client's thoughts about wanting to hurt herself. When a client expresses not deserving to eat due to lack of money, it raises concerns about her mental and emotional well-being. Assessing for suicidal ideation is crucial in this situation to ensure the client's immediate safety. Options B, C, and D are not the most critical information to obtain in this scenario. While medication history, family support, and community resources are important aspects of care, in this context, the client's mental health and risk of self-harm take precedence.

4. An elderly client with a history of falls is being discharged from the hospital. Which intervention should the home health nurse implement to reduce the client's risk of falling at home?

• A. Install grab bars in the bathroom
• B. Provide a walker for ambulation
• C. Educate the client on fall prevention strategies
• D. Refer the client to a physical therapist

Correct answer: A

Rationale: Installing grab bars in the bathroom is crucial to reducing the elderly client's risk of falling at home. Grab bars provide physical support and stability, especially in areas like the bathroom where slips and falls are common among older adults. While providing a walker for ambulation (Choice B) can assist with mobility, it may not directly address the environmental hazards at home. Educating the client on fall prevention strategies (Choice C) is important but may not be sufficient if the physical environment is not modified to reduce fall risks. Referring the client to a physical therapist (Choice D) may help improve strength and balance but does not directly address the immediate environmental risk of falling at home.

5. A male client who had abdominal surgery has a nasogastric tube for suction, oxygen via nasal cannula, and complains of dry mouth. Which action should the nurse implement?

• A. Apply a petroleum-based lubricant to the lips.
• B. Give sips of water.
• C. Provide ice chips.
• D. Apply a water-soluble lubricant to the lips, oral mucosa, and nares.

Correct answer: D

Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.

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