Nursing Elites

1. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?

• A. Offer fluids every 2 hours.
• B. Document the client's behavior prior to being placed in seclusion.
• C. Discuss with the client their inappropriate behavior prior to seclusion.
• D. Assess the client's behavior every hour.

Correct answer: B

Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.

2. A nurse is caring for a client who has a new prescription for metformin. Which of the following findings in the client's medical history should the nurse report to the provider?

• A. History of hypertension
• B. History of polycystic ovary syndrome
• C. History of asthma
• D. History of kidney disease

Correct answer: D

Rationale: The correct answer is D, history of kidney disease. Metformin should be used with caution in clients with kidney disease due to the risk of lactic acidosis, a serious complication. Reporting this finding to the provider is crucial for assessing the appropriateness of continuing metformin therapy. Choices A, B, and C do not contraindicate the use of metformin, so they are not the priority for reporting.

3. A nurse is caring for an adult client who has prescriptions for multiple medications. Which of the following is an age-related change that increases the risk for adverse effects from these medications?

• A. Rapid gastric emptying
• B. Prolonged medication half-life
• C. Increased medication elimination
• D. Decreased medication sensitivity

Correct answer: B

Rationale: The correct answer is B: Prolonged medication half-life. As clients age, their metabolism tends to slow down, leading to a prolonged half-life of medications in the body. This extended presence of drugs can increase the risk for adverse effects as the substances accumulate. Choice A, rapid gastric emptying, is not an age-related change and actually decreases the time medications spend in the stomach, potentially reducing their effectiveness. Choice C, increased medication elimination, is not an age-related change either; in fact, aging can lead to decreased renal function, affecting drug elimination. Choice D, decreased medication sensitivity, is not an age-related change that directly increases the risk for adverse effects; rather, it may lead to requiring higher doses for effectiveness but does not inherently increase the risk of adverse effects.

4. A nurse is caring for a client who is 36 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 92/min
• B. Serosanguineous wound drainage
• C. Yellow wound drainage
• D. Blood pressure of 118/76 mm Hg

Correct answer: C

Rationale: Yellow wound drainage can indicate infection, especially 36 hours postoperative, and should be reported to the provider promptly. Serosanguineous drainage is a normal finding in the early stages of wound healing, and a heart rate of 92/min and a blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client. Therefore, the nurse should prioritize reporting the yellow wound drainage as it may require immediate intervention.

5. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

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