Nursing Elites

1. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

• A. Place the client in a room close to the nurses' station
• B. Use a bed exit alarm
• C. Encourage family members to stay with the client at all times
• D. Raise all four side rails

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

2. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

3. How should a healthcare professional care for a patient with a colostomy?

• A. Empty the colostomy bag regularly
• B. Provide a high-fiber diet
• C. Monitor for signs of infection
• D. Change the colostomy bag every 3 days

Correct answer: A

Rationale: Emptying the colostomy bag regularly is essential to prevent leakage and infection. By regularly emptying the bag, the risk of irritation to the skin surrounding the stoma is reduced. Providing a high-fiber diet is important for overall bowel health but is not directly related to colostomy care. While monitoring for signs of infection is crucial, the primary focus should be on proper bag emptying. Changing the colostomy bag every 3 days may not be necessary for all patients and could vary based on individual needs and the type of colostomy.

4. Which of the following interventions is the best to improve the healing of a pressure ulcer for a client with a low serum albumin level?

• A. Provide high-calorie, high-protein supplements
• B. Consult a dietitian to create a high-protein diet plan
• C. Administer nutritional supplements
• D. Increase IV fluids to prevent dehydration

Correct answer: B

Rationale: Consulting a dietitian to create a high-protein diet plan is the best intervention for a client with a low serum albumin level to promote healing. This approach ensures that the client receives the specific nutrients needed for wound healing. Providing high-calorie, high-protein supplements (choice A) may not address the specific nutritional deficiencies of the client. Administering nutritional supplements (choice C) is vague and may not target the necessary nutrients for wound healing. Increasing IV fluids (choice D) is important for hydration but does not directly address the nutritional needs of the client to improve ulcer healing.

5. A client with coronary artery disease (CAD) is taking a low-dose aspirin daily. The nurse is reinforcing teaching with the client. The nurse should include that this medication has which of the following therapeutic effects?

• A. Analgesic
• B. Antiplatelet
• C. Anticoagulant
• D. Thrombolytic

Correct answer: B

Rationale: The correct answer is B: Antiplatelet. Aspirin works by inhibiting platelet aggregation, making it an antiplatelet agent. This effect helps reduce the risk of blood clot formation in clients with CAD. Choice A, Analgesic, is incorrect because aspirin's primary action in this context is not pain relief. Choice C, Anticoagulant, is incorrect as aspirin does not directly inhibit coagulation factors. Choice D, Thrombolytic, is incorrect as aspirin does not actively break down clots but rather prevents their formation.

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