Nursing Elites

1. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused.
• B. Request a prescription for PRN restraints when the client is wandering.
• C. Dim the lighting in the client's room.
• D. Leave one side rail up on the client's bed.

Correct answer: C

Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.

2. A nurse is providing discharge instructions to a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should have my vision checked regularly while taking this medication.
• B. This medication can cause my urine to turn reddish-orange.
• C. I need to wear sunscreen and protective clothing while taking this medication.
• D. I will discontinue this medication if I experience nausea.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause a harmless reddish-orange discoloration of body fluids, including urine. Choice A is not related to rifampin; vision changes are not a common side effect of the medication. Choice C is more relevant to medications that cause photosensitivity reactions, not specifically rifampin. Choice D is incorrect because nausea is a common side effect of rifampin, but it does not warrant immediate discontinuation of the medication.

3. What is the primary nursing intervention for a patient experiencing hypoglycemia?

• A. Administer IV fluids
• B. Check blood sugar levels
• C. Provide oral glucose
• D. Recheck blood sugar levels in 15 minutes

Correct answer: D

Rationale: The correct answer is to recheck blood sugar levels in 15 minutes. This intervention is crucial to ensure that the hypoglycemia has been effectively corrected after the initial treatment. Administering IV fluids may be necessary in cases of severe dehydration but is not the primary intervention for hypoglycemia. Checking blood sugar levels is important, but the primary intervention should focus on treating the low blood sugar levels first, which is done by providing oral glucose. However, the most critical step after providing initial treatment is to recheck blood sugar levels to confirm that they have improved to safe levels.

4. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Polyuria
• C. Hypertension
• D. Weight loss

Correct answer: B

Rationale: Polyuria is the correct answer. Diabetes insipidus is characterized by the inability to concentrate urine, leading to excessive urination (polyuria) and thirst. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. While dehydration from the excessive urination can lead to hypotension rather than hypertension, and weight loss can occur due to fluid loss, the most specific and significant finding expected in diabetes insipidus is polyuria.

5. A nurse is caring for a client who is at risk for developing a deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?

• A. Massage the client's legs every 2 hours.
• B. Instruct the client to sit with the legs crossed.
• C. Administer prophylactic antibiotics.
• D. Apply sequential compression devices to the client's legs.

Correct answer: D

Rationale: The correct answer is D: Apply sequential compression devices to the client's legs. Sequential compression devices help prevent venous stasis and reduce the risk of DVT by promoting blood flow in the legs. Massaging the client's legs every 2 hours (choice A) may dislodge a clot if present, leading to a higher risk of embolism. Instructing the client to sit with the legs crossed (choice B) can impede blood flow and increase the risk of DVT. Administering prophylactic antibiotics (choice C) is not indicated for preventing DVT, as antibiotics are used to treat infections caused by bacteria, not to prevent blood clots.

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