Nursing Elites

1. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client?

• A. Use a bed exit alarm system
• B. Raise all four side rails while the client is in bed
• C. Apply soft wrist restraints
• D. Dim the lights in the client's room

Correct answer: A

Rationale: The correct answer is A: Using a bed exit alarm system. A bed exit alarm alerts staff when a client with dementia attempts to leave the bed, reducing the risk of falls. Choice B is incorrect because raising all four side rails can lead to restraint-related injuries and is not recommended. Choice C is incorrect as applying wrist restraints should be avoided due to the risk of injury and decreased mobility. Choice D is incorrect as dimming the lights in the client's room does not directly address the risk of injury associated with dementia.

2. A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?

• A. White blood cell count of 8,000/mm³
• B. Potassium level of 4.0 mEq/L
• C. Creatinine level of 1.0 mg/dL
• D. Hemoglobin level of 12 g/dL

Correct answer: C

Rationale: An elevated creatinine level indicates impaired kidney function, which may affect the client's ability to undergo surgery. The other laboratory values (white blood cell count, potassium level, and hemoglobin level) are within normal ranges and do not directly impact the client's readiness for surgery.

3. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

4. A healthcare professional is managing a client with a wound infection. What is the priority action?

• A. Change the wound dressing every 12 hours
• B. Perform a wound culture before applying antibiotics
• C. Apply a wet-to-dry dressing to the wound
• D. Cleanse the wound with a solution of alcohol and water

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial to identify the specific pathogen causing the infection. This helps in selecting the most effective antibiotics for treatment. Changing the wound dressing, applying a wet-to-dry dressing, or cleansing the wound are important interventions but should follow the assessment and identification of the infecting organism through a wound culture to guide appropriate treatment.

5. A healthcare professional is reviewing the medical record of a client who has a prescription for levothyroxine. Which of the following findings should the healthcare professional identify as an indication of a need for dosage adjustment?

• A. Tremors
• B. Increased appetite
• C. Bradycardia
• D. Diarrhea

Correct answer: B

Rationale: Increased appetite may indicate that the client is experiencing symptoms of hyperthyroidism due to an excessive dose of levothyroxine. This finding suggests a need for a dosage adjustment to prevent potential complications. Tremors are more commonly associated with hyperthyroidism, not necessarily indicating a need for dosage adjustment. Bradycardia and diarrhea are not typical signs of an incorrect levothyroxine dosage and would not directly warrant a need for adjustment.

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