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 nurse is preparing to administer a blood transfusion. What is the first action?

• A. Administer the blood through an IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Ensure the client eats before starting the transfusion

Correct answer: B

Rationale: The correct first action when preparing to administer a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to prevent transfusion reactions and complications. Option A is incorrect because blood transfusions should not be administered through an IV push due to the risk of rapid infusion and adverse reactions. Option C is incorrect because blood should be transfused at room temperature, not body temperature. Option D is incorrect because it is not necessary for the client to eat before a blood transfusion.

3. A nurse is caring for a client who has a prescription for metoprolol. For which of the following findings should the nurse withhold the medication?

• A. Heart rate 56/min.
• B. Oxygen saturation 93%.
• C. Respiratory rate 18/min.
• D. Blood pressure 118/74 mm Hg.

Correct answer: A

Rationale: The correct answer is A: Heart rate 56/min. Metoprolol, a beta blocker, should be withheld if the client's heart rate is below 60/min to prevent further bradycardia. Choices B, C, and D are within normal ranges and do not indicate a need to withhold metoprolol.

4. What guides behavior and decision making based on values and beliefs?

• A. Morals
• B. Beliefs
• C. Ethics
• D. Autonomy

Correct answer: A

Rationale: Morals are the values and beliefs that guide behavior and decision-making. While beliefs are part of the equation, morals specifically dictate how individuals act and make choices. Ethics, on the other hand, refer to a system of moral principles governing conduct. Autonomy, although important, is not directly related to the values and beliefs that guide behavior and decision making.

5. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?

• A. Remain sedentary for 2-3 days
• B. Walk for 1-2 hours each day
• C. Wear compression stockings only at night
• D. Elevate legs while sitting

Correct answer: B

Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.

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