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. What is the priority intervention for a patient presenting with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.

3. A client receiving a blood transfusion develops a fever. What action should the nurse take?

• A. Stop the transfusion immediately.
• B. Administer an antihistamine as prescribed.
• C. Administer a diuretic as prescribed.
• D. Increase the transfusion rate.

Correct answer: A

Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.

4. How should a healthcare provider monitor a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT (activated partial thromboplastin time) when a patient is receiving heparin therapy. aPTT monitoring is essential for assessing the therapeutic effectiveness of heparin, ensuring the patient is within the desired therapeutic range to prevent both clotting and bleeding. Monitoring platelet count (Choice B) is important for assessing for heparin-induced thrombocytopenia but is not the primary monitoring parameter for heparin therapy. Monitoring sodium levels (Choice C) and calcium levels (Choice D) are not directly related to assessing the therapeutic effectiveness or potential side effects of heparin therapy.

5. A client with COPD is receiving discharge teaching. Which statement indicates an understanding of the teaching?

• A. I will avoid breathing deeply while using my incentive spirometer.
• B. I will limit my fluid intake to 1 liter per day.
• C. I will exercise in an area that is humid.
• D. I will use pursed-lip breathing techniques.

Correct answer: D

Rationale: The correct answer is D. Using pursed-lip breathing techniques is beneficial for clients with COPD as it helps control shortness of breath by keeping airways open longer. Option A is incorrect as deep breathing while using an incentive spirometer is essential to prevent complications such as atelectasis. Option B is incorrect because limiting fluid intake to 1 liter per day is not a standard recommendation for clients with COPD. Option C is incorrect as exercising in a humid area can exacerbate breathing difficulties for clients with COPD.

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