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 client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?

• A. Drink 1 liter of water per day.
• B. Take a laxative every morning.
• C. Increase your intake of refined grains.
• D. Walk for at least 30 minutes every day.

Correct answer: D

Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.

3. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?

• A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
• B. Reinforcing teaching with a client who is learning to walk with a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure ulcer

Correct answer: C

Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.

4. How should a healthcare professional manage a patient with a tracheostomy?

• A. Monitor airway patency and provide humidified oxygen
• B. Provide education on tracheostomy care
• C. Suction airway secretions and change tracheostomy ties
• D. Provide a high-protein diet and ensure fluid restriction

Correct answer: A

Rationale: Correct answer: Monitoring airway patency and providing humidified oxygen is crucial in managing a patient with a tracheostomy to ensure proper breathing and oxygenation. Ensuring the airway is clear and providing oxygen support are immediate priorities. Providing education on tracheostomy care (Choice B) is important for long-term management but not the immediate priority. Suctioning airway secretions and changing tracheostomy ties (Choice C) are tasks that may be necessary but do not address the primary concern of maintaining airway patency. Providing a high-protein diet and ensuring fluid restriction (Choice D) are unrelated to the immediate management of a tracheostomy.

5. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective?

• A. Cardiac workload decreases
• B. Blood pressure increases
• C. Respiratory rate increases
• D. Temperature decreases

Correct answer: A

Rationale: The correct answer is A: Cardiac workload decreases. Digoxin helps reduce cardiac workload in clients with heart failure, improving symptoms. This reduction in workload indicates that the medication is effective. Choice B, blood pressure increases, is incorrect because digoxin typically does not directly affect blood pressure. Choice C, respiratory rate increases, is incorrect as an increased respiratory rate is not a typical indicator of digoxin effectiveness. Choice D, temperature decreases, is also incorrect as digoxin does not typically affect body temperature.

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