Nursing Elites

1. A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)

• A. Turn off the bed alarm
• B. Use physical restraints
• C. Maintain the bed in the lowest position
• D. Apply a vest restraint

Correct answer: C

Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.

2. When reviewing the health history of an older adult with a hip fracture, what should a nurse identify as a risk factor for developing pressure injuries?

• A. Malnutrition
• B. Poor hygiene
• C. Urinary incontinence
• D. Immobility

Correct answer: C

Rationale: Urinary incontinence is a risk factor for skin breakdown, which can lead to the development of pressure injuries. While malnutrition, poor hygiene, and immobility are important considerations in overall patient care, they are not specifically identified as significant risk factors for pressure injuries in this scenario.

3. A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?

• A. Steamed carrots
• B. Orange slices
• C. Mashed potatoes
• D. Baked chicken

Correct answer: B

Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.

4. A nurse is teaching a group of assistive personnel about expected integumentary changes in older adults. What change should the nurse include?

• A. Increase in oil production
• B. Decrease in elasticity
• C. Increase in pigmentation
• D. Decrease in moisture levels

Correct answer: B

Rationale: The correct answer is B: Decrease in elasticity. As individuals age, their skin tends to lose elasticity, becoming less flexible. This results in wrinkles and sagging skin. Option A, increase in oil production, is not typically an expected integumentary change in older adults. Option C, increase in pigmentation, may occur due to sun exposure or age spots but is not a universal change. Option D, decrease in moisture levels, is not a primary integumentary change associated with aging.

5. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

• A. Heart rate of 80 beats per minute
• B. Heart rate of 120 beats per minute
• C. Blood pressure of 110/70 mmHg
• D. Respiratory rate of 16 breaths per minute

Correct answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

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