Nursing Elites

1. A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?

• A. Place the bed in the lowest position, instruct the patient to remain in bed, ensure the bedside table is within reach.
• B. Instruct the patient to use the call light, apply an ambulation alarm to the patient’s leg, check on the patient hourly.
• C. Assign a sitter to monitor the patient, raise the bed rails, provide the patient with a call button.
• D. Check on the patient every two hours, provide verbal reminders to use the call light, lock the bed wheels.

Correct answer: B

Rationale: In this scenario, the correct actions for the nurse to take involve ensuring patient safety and fall prevention measures. Choice B is the correct answer because instructing the patient to use the call light allows them to signal for help, applying an ambulation alarm helps detect movement, and checking on the patient hourly increases monitoring frequency. These actions are essential for preventing falls in a disoriented patient with a history of falls. Choices A, C, and D are incorrect: A does not provide adequate monitoring or fall prevention measures, C relies solely on assigning a sitter without utilizing technological aids, and D lacks continuous monitoring and specific fall prevention strategies.

2. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?

• A. Increase calcium intake
• B. Provide a diet high in potassium
• C. Restrict protein intake
• D. Increase fluid intake

Correct answer: C

Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.

3. A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?

• A. Encourage the mother to breastfeed the newborn
• B. Gavage feed 60 mL (2 oz) of glucose water
• C. Administer 10 mL of D5W via IV
• D. Recheck the glucose level in 2 hours

Correct answer: A

Rationale: Encouraging the mother to breastfeed the newborn is the most appropriate action in this scenario. Breastfeeding can quickly raise blood glucose levels in newborns. A blood glucose level of 45 mg/dL is often acceptable in newborns, but close monitoring is necessary. Gavage feeding with glucose water or administering D5W via IV may not be necessary at this point and could lead to potential risks of overfeeding or hypoglycemia. Rechecking the glucose level in 2 hours may delay necessary intervention, as breastfeeding can promptly address the low blood glucose levels.

4. A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

• A. A client who has a urine specific gravity of 1.010.
• B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr.
• C. A client who has a hematocrit of 45%.
• D. A client who has a temperature of 39°C (102°F).

Correct answer: D

Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.

5. A nurse is teaching a group of clients about measures to prevent the development of skin cancer. Which of the following client statements indicates a need for further teaching?

• A. I will avoid going outside between 1000 and 1600.
• B. I will wear a wide-brimmed hat when I go outside.
• C. I will make sure to apply sunscreen with SPF 10 when I’m in the sun.
• D. I will reapply my sunscreen every 2 hours.

Correct answer: C

Rationale: The correct answer is C. An SPF of at least 15 is recommended to effectively protect against harmful UV rays. A sunscreen with an SPF of 10 is insufficient and does not provide adequate protection against skin cancer. Choices A, B, and D demonstrate good understanding of sun protection measures, such as avoiding peak sun hours, wearing protective clothing like a wide-brimmed hat, and reapplying sunscreen every 2 hours, which are all effective strategies to prevent skin cancer.

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