Nursing Elites

1. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

• A. Implement a regular toileting schedule
• B. Encourage the client to wear athletic socks when ambulating
• C. Place all four bed rails in the upright position
• D. Require a family member to remain at the bedside

Correct answer: A

Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.

2. What intervention is key when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

3. What is the first priority for a patient in respiratory distress?

• A. Administer oxygen
• B. Assess airway patency
• C. Monitor oxygen saturation
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, the primary concern is ensuring an adequate oxygen supply to the body. By administering oxygen, you can help improve oxygenation, which is crucial for the patient's overall well-being. Assessing airway patency is important but administering oxygen takes precedence as it directly addresses the oxygenation concern. Monitoring oxygen saturation is also essential, but the immediate action should be to provide oxygen. Calling for assistance can be important but is not the first priority when dealing with a patient in respiratory distress.

4. Which dietary advice is most appropriate for a client with chronic kidney disease?

• A. Increase intake of fruits and vegetables
• B. Limit intake of potassium-rich foods
• C. Increase intake of dairy products
• D. Reduce intake of protein-rich foods

Correct answer: B

Rationale: The most appropriate dietary advice for a client with chronic kidney disease is to limit intake of potassium-rich foods. In chronic kidney disease, the kidneys have difficulty filtering potassium from the blood, leading to high levels that can be harmful. Therefore, reducing potassium intake is crucial to prevent complications. Choices A, C, and D are not the best options for individuals with chronic kidney disease. Increasing intake of fruits and vegetables (choice A) may actually increase potassium consumption. Increasing intake of dairy products (choice C) can lead to higher phosphorus and potassium levels. Reducing protein-rich foods (choice D) is not the primary focus in the early stages of chronic kidney disease, as protein is necessary for overall health unless kidney function declines significantly.

5. When caring for a client experiencing delirium, which of the following is essential?

• A. Controlling behavioral symptoms with low-dose psychotropics
• B. Identifying the underlying causative condition or illness
• C. Manipulating the environment to increase orientation
• D. Decreasing or discontinuing all previously prescribed medications

Correct answer: B

Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.

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