Nursing Elites

1. A nurse is caring for a client with Alzheimer's disease who wanders frequently. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a well-lit area to reduce wandering.
• B. Ensure that the client wears an identification bracelet at all times.
• C. Keep the client's bed in the lowest position.
• D. Use physical restraints to prevent wandering.

Correct answer: B

Rationale: The correct answer is to ensure that the client wears an identification bracelet at all times. This intervention helps staff recognize clients who wander and ensures their safety. Placing the client in a well-lit area (Choice A) may be helpful in some cases but does not directly address the issue of wandering. Keeping the client's bed in the lowest position (Choice C) is important for fall prevention but is not directly related to wandering behavior. Using physical restraints (Choice D) is not recommended as the first-line intervention for wandering and should be avoided due to ethical concerns and potential risks.

2. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

3. Which electrolyte imbalance is commonly seen in patients receiving furosemide?

• A. Hypokalemia
• B. Hypercalcemia
• C. Hyponatremia
• D. Hyperkalemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance necessitates close monitoring to prevent complications such as cardiac arrhythmias. Choices B, C, and D are incorrect. Hypercalcemia is not a common side effect of furosemide. Hyponatremia is more commonly associated with other medications like thiazide diuretics. Hyperkalemia is the opposite electrolyte imbalance and is not typically seen with furosemide use.

4. A nurse is planning care for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

• A. Serum calcium level
• B. Blood glucose level
• C. Serum albumin level
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, Serum albumin level. Monitoring the serum albumin level helps assess the nutritional effectiveness of total parenteral nutrition (TPN). Serum albumin is a protein that reflects the long-term nutritional status of a patient. Serum calcium level (choice A) is not directly related to TPN effectiveness. Blood glucose level (choice B) is important to monitor in diabetic patients but is not the primary indicator of TPN efficacy. Serum sodium level (choice D) is more related to fluid balance and electrolyte status rather than the effectiveness of TPN.

5. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Redness and warmth in the calf
• C. Oxygen saturation of 95%
• D. Temperature of 37.3°C (99.1°F)

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.

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