Nursing Elites

1. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

• A. Lock beds and wheelchairs when not in use
• B. Administer a sedative at bedtime
• C. Provide information about home safety checks
• D. Teach balance and strengthening exercises

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

2. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

• A. Monitor the patient's vital signs.
• B. Check the patient's weight daily.
• C. Measure the patient's intake and output.
• D. Monitor the patient's urine color.

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

3. What are the nursing interventions for a patient with pneumonia?

• A. Providing fluids and rest
• B. Monitoring lung sounds and respiratory rate
• C. Encouraging coughing and deep breathing exercises
• D. Administering antibiotics and providing oxygen therapy

Correct answer: B

Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.

4. A patient on mechanical ventilation experiences a sudden drop in oxygen saturation. What should the nurse check first?

• A. Check the ventilator tubing for disconnection.
• B. Increase the patient's oxygen flow.
• C. Perform a full physical assessment.
• D. Reassess the patient's oxygen levels after 5 minutes.

Correct answer: A

Rationale: The correct answer is to check the ventilator tubing for disconnection first when a patient on mechanical ventilation experiences a sudden drop in oxygen saturation. This is crucial because equipment malfunction, such as tubing disconnection, can lead to decreased oxygen delivery, resulting in a drop in oxygen saturation. Checking the tubing ensures that the ventilation system is functioning properly and that the patient is receiving the necessary oxygen. Option B is incorrect because increasing oxygen flow without checking for equipment issues may not address the root cause of the drop in saturation. Option C is not the priority in this situation as the immediate focus should be on assessing and ensuring the functioning of the ventilation equipment. Option D delays addressing the potential equipment malfunction, which could worsen the patient's condition if not promptly resolved.

5. How is the effectiveness of a diuretic in a patient with heart failure evaluated?

• A. Checking daily weights and lung sounds for improvement
• B. Assessing the patient's blood pressure and urine output
• C. Monitoring for weight loss and reduction in edema
• D. Measuring the patient's heart rate and lung sounds

Correct answer: A

Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.

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