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 of 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 one soft wrist restraint
• D. Dim the lights in the client's room

Correct answer: A

Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.

2. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

3. A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?

• A. The client advances the cane 18 inches in front of the foot
• B. The client holds the cane in the left hand
• C. The client advances the cane and the right leg simultaneously
• D. The client holds the cane with the elbow flexed at 60°

Correct answer: B

Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.

4. How should a healthcare professional manage a patient with a suspected stroke?

• A. Monitor for changes in neurological status and administer thrombolytics
• B. Monitor for speech difficulties and administer oxygen
• C. Provide IV fluids and monitor blood pressure
• D. Administer pain relief and monitor for respiratory failure

Correct answer: A

Rationale: Corrected Rationale: When managing a patient with a suspected stroke, it is crucial to monitor for changes in neurological status as this can provide important information about the patient's condition. Administering thrombolytics, if indicated, is a critical intervention in the acute phase of an ischemic stroke to help dissolve blood clots and restore blood flow to the brain. This choice is the correct answer because it addresses the immediate management needs of a patient with a suspected stroke. Choices B, C, and D are incorrect because while monitoring for speech difficulties, administering oxygen, providing IV fluids, monitoring blood pressure, administering pain relief, and monitoring for respiratory failure are important aspects of patient care, they are not the primary interventions for managing a suspected stroke.

5. A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?

• A. Administer an antiemetic
• B. Irrigate the NG tube with sterile water
• C. Increase the suction setting
• D. Replace the NG tube

Correct answer: B

Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.

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