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 teaching a newly licensed nurse about ergonomic principles. Which action by the newly licensed nurse indicates an understanding of the teaching?

• A. Stand with feet together when lifting a client.
• B. Raise the client's head of bed before pulling the client up.
• C. Use a mechanical lift to move a client.
• D. Place a gait belt around the client's chest before assisting the client.

Correct answer: C

Rationale: The correct answer is C: 'Use a mechanical lift to move a client.' Using a mechanical lift is an essential ergonomic principle to prevent injury and ensure safe client handling. Choice A is incorrect because standing with feet together when lifting a client can lead to instability and improper weight distribution. Choice B is incorrect as raising the client's head of bed before pulling the client up does not primarily relate to ergonomic principles. Choice D is incorrect because while using a gait belt is important for assisting clients with mobility, it is not specifically related to ergonomic principles for safe handling.

3. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer oxygen
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.

4. A nurse is reviewing admission prescriptions for a group of clients. Which prescription should the nurse identify as complete?

• A. Furosemide 20 mg BID
• B. Aspirin 1 tablet daily
• C. Nitroglycerin transdermal patch
• D. Metoprolol 5 mg IV now

Correct answer: A

Rationale: The correct answer is A. A complete prescription should include the medication name (Furosemide), dosage (20 mg), and administration schedule (BID - twice daily). Choice B is missing the dosage of Aspirin, choice C lacks the dosage information for Nitroglycerin, and choice D does not specify the administration schedule for Metoprolol.

5. A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?

• A. Blood urea nitrogen (BUN) 25 mg/dL
• B. Serum creatinine 1.5 mg/dL
• C. Serum glucose 110 mg/dL
• D. White blood cell (WBC) count 5,000/mm3

Correct answer: A

Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.

Similar Questions