Nursing Elites

1. A nurse is planning care for a client who has dementia and is frequently agitated. Which of the following interventions should the nurse include in the plan of care?

• A. Offer the client several choices when scheduling activities.
• B. Confront the client when inappropriate behavior occurs.
• C. Use a calm, reassuring approach when speaking to the client.
• D. Encourage the client to engage in stimulating activities.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.

2. A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?

• A. Witness the waste of the controlled substance by another nurse
• B. Dispose of the controlled substance by yourself
• C. Leave the controlled substance in the client's room for later use
• D. Document the administration and sign off at the end of the shift

Correct answer: A

Rationale: The correct action for the nurse preparing to administer a controlled substance is to witness the waste of the controlled substance by another nurse. This practice is crucial to prevent misuse and ensure accurate documentation. Choice B is incorrect because disposing of the controlled substance by oneself without proper witnessing is not in accordance with safety protocols. Choice C is incorrect as leaving a controlled substance unattended in a client's room poses risks of diversion or unauthorized access. Choice D is incorrect because documenting the administration and signing off at the end of the shift is important but does not specifically address the issue of witnessing the waste of a controlled substance, which is a critical step in ensuring proper handling and accountability.

3. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

• A. Insert the catheter 7.5 cm (3 in) into the urethra.
• B. Insert the catheter until urine flow is established.
• C. Cleanse the catheter with sterile water before insertion.
• D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

4. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min
• B. White blood cell count of 9,000/mm3
• C. Temperature of 37.8°C (100°F)
• D. Blood pressure of 118/78 mm Hg

Correct answer: C

Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.

5. A nurse is providing discharge teaching to a client who has had a stroke. Which of the following instructions should the nurse include?

• A. Avoid taking anticoagulant medication.
• B. Limit fluid intake to 1,000 mL per day.
• C. Avoid isometric exercises during recovery.
• D. Perform range-of-motion exercises daily.

Correct answer: D

Rationale: The correct answer is D: Perform range-of-motion exercises daily. After a stroke, performing range-of-motion exercises can help prevent complications such as joint stiffness and contractures. Options A, B, and C are incorrect. Anticoagulant medications are often prescribed to prevent blood clots after a stroke, fluid intake should be adequate unless indicated otherwise, and isometric exercises can be beneficial during recovery.

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