Nursing Elites

1. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

2. What is the first intervention when a patient has difficulty breathing post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the initial intervention for a patient experiencing breathing difficulties post-surgery. Providing oxygen helps improve oxygenation and alleviate respiratory distress. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in addressing hypoxia and respiratory compromise.

3. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

• A. Blow as hard as possible into the mouthpiece.
• B. Exhale quickly and forcefully after taking a deep breath.
• C. Inhale as deeply as possible and then blow into the mouthpiece.
• D. Take a deep breath and hold it for 5 seconds before exhaling.

Correct answer: B

Rationale: The correct answer is B because the client should exhale quickly and forcefully into the peak flow meter after taking a deep breath to measure peak expiratory flow. Choice A is incorrect as blowing as hard as possible may not provide an accurate reading. Choice C is incorrect because inhaling deeply before blowing can affect the results. Choice D is incorrect as holding the breath before exhaling is not part of using a peak flow meter.

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

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

5. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

• A. Stands with feet together when lifting a client up in bed.
• B. Raises the client's head of bed before pulling the client up.
• C. Uses a mechanical lift to move a client from bed to chair.
• D. Places a gait belt around the client's upper chest before assisting the client to stand.

Correct answer: C

Rationale: The correct answer is C because using a mechanical lift is an ergonomic practice that ensures safe body mechanics and prevents injuries. Choice A is incorrect as standing with feet together when lifting a client does not promote proper body mechanics. Choice B is incorrect as raising the client's head of bed before pulling the client up is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's upper chest is a safety measure for assisting with standing but does not address ergonomic principles.

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