Nursing Elites

1. A nurse is assessing a client who is at risk for falls. Which of the following findings should the nurse recognize as increasing the client's risk of falling?

• A. Normal gait
• B. Recent history of dizziness
• C. 20/20 vision
• D. Takes a multivitamin daily

Correct answer: B

Rationale: The correct answer is B: Recent history of dizziness. A recent history of dizziness significantly increases the risk of falling, as dizziness can impair balance and coordination. Having a normal gait (choice A) and 20/20 vision (choice C) are not factors that directly increase the risk of falling. Taking a multivitamin daily (choice D) does not inherently contribute to an increased risk of falling unless it causes dizziness as a side effect, which is not specified in the question.

2. A client is being treated for eclampsia. What is a priority nursing intervention?

• A. Assess for hyperreflexia
• B. Administer oxygen
• C. Monitor blood pressure every 15 minutes
• D. Prepare for delivery

Correct answer: A

Rationale: The correct answer is to 'Assess for hyperreflexia.' Eclampsia is a severe complication of pregnancy that involves seizures. Hyperreflexia, an overactive or overresponsive reflex, is often an early sign of impending eclampsia. By assessing for hyperreflexia, nurses can identify this warning sign and take preventive measures to manage the condition before seizures occur. Administering oxygen (Choice B) may be necessary but is not the priority in this situation. Monitoring blood pressure (Choice C) is important but assessing for hyperreflexia takes precedence as it can lead to immediate life-threatening complications. While preparing for delivery (Choice D) may ultimately be necessary, the immediate priority is to assess for hyperreflexia to prevent seizures.

3. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40 mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following indicates she is dehydrated?

• A. Urine specific gravity of 1.035
• B. Oliguria, increased urine concentration, and an increase in urine specific gravity greater than 1.030
• C. Polyuria
• D. Hypotension

Correct answer: B

Rationale: Oliguria (reduced urine output), increased urine concentration, and a urine specific gravity greater than 1.030 are indicative of dehydration, particularly in clients using diuretics excessively. Choice A is incorrect because a urine specific gravity of 1.035 is high, indicating concentrated urine but not specifically dehydration. Choice C, polyuria, refers to increased urine output and is not consistent with dehydration. Choice D, hypotension, is a sign of fluid volume deficit but is not specific to dehydration as described in the scenario.

4. A nurse is caring for a client with a sealed radiation implant. Which action should the nurse take?

• A. Remove dirty linens after double-bagging
• B. Wear a dosimeter badge
• C. Limit visitors to 1 hour per day
• D. Ensure family remains 3 feet away from the client

Correct answer: B

Rationale: The correct answer is B: Wear a dosimeter badge. When caring for a client with a sealed radiation implant, the nurse should wear a dosimeter badge to monitor radiation exposure. This badge helps measure the amount of radiation the nurse is exposed to during care. Choice A is incorrect because removing dirty linens after double-bagging is not directly related to managing radiation exposure. Choice C is incorrect as there is no specific time limit on visitors mentioned in the context of a sealed radiation implant. Choice D is incorrect as there is no evidence supporting the need for family members to stay a specific distance away from the client.

5. A healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the healthcare provider monitor?

• A. Serum glucose levels
• B. Serum potassium levels
• C. Blood pressure
• D. Both A and B

Correct answer: D

Rationale: When caring for a client receiving total parenteral nutrition (TPN), monitoring serum glucose levels is essential due to the impact TPN can have on glucose metabolism. Additionally, electrolytes like potassium should be monitored as they can be affected by TPN administration. Blood pressure monitoring is not directly related to TPN administration, making choices A and B the correct options to monitor in this scenario.

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