Nursing Elites

1. A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I will take a hot bath before going to bed.”
• B. “I will take my new medication in the evening.”
• C. “I will leave a light on in my bathroom at night.”
• D. “I will weigh myself once weekly.”

Correct answer: C

Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.

2. When planning care for a newly admitted elderly client who is severely dehydrated, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?

• A. Converse with the client to determine if the mucous membranes are impaired
• B. Report hourly outputs of less than 30 ml/hr
• C. Monitor client's ability to move in the bed
• D. Check skin turgor every 4 hours

Correct answer: B

Rationale: The correct answer is B. Assigning the UAP to report hourly outputs of less than 30 ml/hr is appropriate as it falls within their scope of practice and does not involve making clinical assessments or decisions. Choices A, C, and D involve tasks that require a higher level of clinical judgment and training. Choice A requires assessing mucous membranes, which is beyond the UAP's scope. Choice C involves assessing movement ability, which requires more specialized training. Choice D involves assessing skin turgor, which also requires a higher level of clinical judgment.

3. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the nurse to take?

• A. Monitor the client's blood glucose level.
• B. Encourage the client to increase fluid intake.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: A

Rationale: The most critical action for the nurse to take when a client with diabetes mellitus presents with symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps in assessing the client's current glycemic status and guides further interventions. Encouraging increased fluid intake (Choice B) may be beneficial in managing dehydration caused by polyuria, but it does not address the underlying cause of hyperglycemia. Administering insulin as prescribed (Choice C) may be necessary based on the blood glucose monitoring results, but monitoring should precede any medication administration. Assessing the client's urine output (Choice D) is important but does not directly address the primary concern of evaluating and managing hyperglycemia in a client with diabetes.

4. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take?

• A. Remove the restraints every 4 hours.
• B. Attach the restraints securely to the side of the client's bed.
• C. Apply the restraints to allow as little movement as possible.
• D. Allow room for two fingers to fit between the client's skin and the restraints.

Correct answer: D

Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security. Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use. Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client. Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.

5. A 10-year-old client is recovering from a splenectomy following a traumatic injury. The client's laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to:

• A. Limit milk and milk products
• B. Encourage bed rest and quiet activities
• C. Plan nursing care around lengthy rest periods
• D. Promote a diet rich in iron

Correct answer: C

Rationale: Encouraging bed rest and quiet activities is crucial for a child recovering from a splenectomy with low hemoglobin and hematocrit levels. This approach helps conserve energy, promotes healing, and allows the body to focus on rebuilding red blood cells. Limiting milk and milk products (Choice A) is not directly related to improving the child's condition. Encouraging bed rest and quiet activities (Choice B) is appropriate as it helps in conserving energy and preventing physical exertion. Promoting a diet rich in iron (Choice D) is beneficial for improving hemoglobin levels in the long term, but immediate rest and recovery take precedence in this scenario.

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