Nursing Elites

1. A nurse is caring for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a well-lit area to reduce wandering.
• B. Use physical restraints to prevent wandering.
• C. Ensure that the client wears an identification bracelet at all times.
• D. Keep the client's bed in the lowest position.

Correct answer: C

Rationale: The correct intervention for a client with Alzheimer's disease who demonstrates confusion and wandering behavior is to ensure that the client wears an identification bracelet at all times. This helps prevent wandering and ensures the client's safety. Placing the client in a well-lit area may be beneficial for orientation but does not directly address wandering behavior. Using physical restraints is not recommended as it can lead to agitation and other complications. Keeping the client's bed in the lowest position is important for fall prevention but does not specifically address the issue of wandering behavior.

2. A healthcare provider is assessing a child who is being treated for bacterial pneumonia. The provider notes an increase in the child's glucose level. The provider should identify this finding as an adverse effect of which of the following medications?

• A. Methylprednisolone.
• B. Ondansetron.
• C. Guaifenesin.
• D. Amoxicillin.

Correct answer: A

Rationale: Correct. Methylprednisolone, a corticosteroid, can lead to increased glucose levels as an adverse effect. Ondansetron is an antiemetic and does not typically cause elevated glucose levels. Guaifenesin is an expectorant and is not associated with raising glucose levels. Amoxicillin is an antibiotic and does not affect glucose levels.

3. A nurse is providing teaching to a client who has osteoporosis. Which of the following instructions should the nurse include?

• A. Take a calcium supplement once daily.
• B. Walk for 30 minutes three times per week.
• C. Avoid weight-bearing exercises.
• D. Increase intake of vitamin D.

Correct answer: B

Rationale: The correct answer is B. Walking regularly is beneficial for clients with osteoporosis as it helps maintain bone density and prevent fractures. Choice A is not the most appropriate because clients with osteoporosis often require more than just calcium supplements. Choice C is incorrect as weight-bearing exercises actually help strengthen bones. Choice D is important, but walking regularly has a more direct impact on bone health in clients with osteoporosis.

4. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?

• A. A chest x-ray reveals increased density in all fields
• B. The client reports feeling less anxious
• C. Diminished breath sounds are auscultated bilaterally
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg

Correct answer: B

Rationale: The correct answer is B because when a client reports feeling less anxious, it suggests that the treatment for a pulmonary embolism is effective. This is a good indicator of the client's overall well-being and response to treatment. Choices A, C, and D are incorrect because a chest x-ray revealing increased density in all fields, diminished breath sounds auscultated bilaterally, and ABG results showing specific values do not directly correlate with the effectiveness of treatment for a pulmonary embolism. While these assessments are important for monitoring the client's condition, the client's subjective report of feeling less anxious provides a more direct insight into the impact of the treatment.

5. A nurse is assessing a client who is 1 day postoperative following hip replacement surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Serosanguineous drainage on the surgical dressing
• C. Blood pressure of 118/76 mm Hg
• D. Urine output of 40 mL/hr

Correct answer: D

Rationale: The correct answer is D: Urine output of 40 mL/hr. A low urine output may indicate kidney complications, such as acute kidney injury, which is a critical finding postoperatively. The nurse should report this immediately to the provider for further evaluation and management. Choices A, B, and C are within normal limits for a client who is 1 day postoperative following hip replacement surgery and do not indicate immediate concerns that require reporting to the provider.

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