Nursing Elites

1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

• A. Increased speech
• B. Lack of sleep
• C. Agitation
• D. Poor concentration

Correct answer: B

Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.

2. What is the most appropriate next step when a client with an NG tube attached to low suctioning becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client on their side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water. When a client with an NG tube attached to low suctioning becomes nauseated and there is a decrease in the flow of gastric secretions, it indicates a possible blockage in the tube. Irrigating the tube with sterile water can help clear the blockage, allowing for proper suctioning and relieving the client's nausea. Increasing the suction pressure (Choice A) can further worsen the issue by potentially causing harm to the client. Turning the client on their side (Choice C) may not address the underlying problem of tube blockage. Replacing the NG tube with a new one (Choice D) should only be considered if other interventions, like irrigation, fail to clear the blockage.

3. A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?

• A. Walk for at least 30 minutes each day
• B. Avoid sunlight exposure
• C. Take vitamin B12 supplements
• D. Increase calcium intake to 1,500 mg per day

Correct answer: D

Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.

4. A nurse is caring for a client with a pressure ulcer and a serum albumin level of 3 g/dL. What should the nurse do first?

• A. Increase the client's protein intake
• B. Consult with a dietitian to improve the client's nutritional status
• C. Administer a protein supplement
• D. Monitor the client's fluid and electrolyte balance

Correct answer: B

Rationale: Consulting with a dietitian is the priority as it ensures that the client receives a comprehensive nutritional assessment and an individualized plan to address the low serum albumin level and pressure ulcer. Increasing protein intake (choice A) and administering a protein supplement (choice C) may be part of the dietitian's recommendations but should not be done without proper assessment and guidance. Monitoring fluid and electrolyte balance (choice D) is important but not the first step in addressing the client's nutritional needs.

5. A nurse is caring for a client with dementia who frequently attempts to get out of bed unsupervised. What is the best intervention?

• A. Use restraints to prevent the client from getting out of bed
• B. Encourage family members to stay with the client at all times
• C. Use a bed exit alarm system
• D. Keep the client's room dark and quiet to reduce stimulation

Correct answer: C

Rationale: The best intervention for a client with dementia who frequently attempts to get out of bed unsupervised is to use a bed exit alarm system (Choice C). A bed exit alarm can alert staff when the client tries to leave the bed, helping to prevent falls. Using restraints (Choice A) is not recommended as it can lead to physical and psychological harm. While having family members present (Choice B) can be beneficial, it may not be feasible at all times. Keeping the client's room dark and quiet (Choice D) may not address the immediate safety concern of the client attempting to get out of bed.

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