Nursing Elites

1. A healthcare professional is reviewing the medical history of a client with dementia. Which of the following findings should be addressed immediately?

• A. Frequent episodes of wandering at night
• B. Restlessness and agitation
• C. Mild confusion during the day
• D. Incontinence

Correct answer: B

Rationale: Restlessness and agitation in clients with dementia should be addressed immediately as they can indicate underlying causes such as pain, discomfort, or unmet needs. Addressing these symptoms promptly can help prevent the escalation of behavioral issues and improve the client's quality of life. While frequent episodes of wandering at night, mild confusion during the day, and incontinence are also important issues to address in clients with dementia, restlessness and agitation usually require immediate attention to ensure the safety and well-being of the client.

2. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

• A. Encourage ambulation
• B. Apply ice packs
• C. Restrict the client's fluid intake
• D. Administer stool softeners

Correct answer: B

Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.

3. A client with left-leg weakness is learning to use a cane. Which teaching point is most appropriate?

• A. Use the cane on the weaker side of the body
• B. Maintain two points of support on the ground at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: B

Rationale: The correct teaching point is to maintain two points of support on the ground at all times when using a cane. This ensures stability and helps distribute weight evenly. Choice A is incorrect because the cane should be used on the stronger side of the body to provide support to the weaker leg. Choice C is incorrect as advancing the cane too far with each step can lead to imbalance. Choice D is incorrect as advancing the cane and the strong leg simultaneously may not provide adequate support for the weaker leg.

4. A nurse is caring for a client who has pneumonia and new onset confusion. Which of the following actions should the nurse take first?

• A. Increase the client's oxygen flow rate
• B. Obtain the client's vital signs
• C. Administer an antibiotic
• D. Notify the provider

Correct answer: A

Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.

5. A nurse is caring for a client who is taking digoxin. Which of the following findings should the nurse identify as a sign of digoxin toxicity?

• A. Bradycardia
• B. Tachycardia
• C. Hypotension
• D. Hyperkalemia

Correct answer: A

Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a cardiac glycoside, can lead to toxicity manifesting as bradycardia due to its effect on the heart's electrical conduction system. Tachycardia (choice B) is not typically associated with digoxin toxicity. Hypotension (choice C) and hyperkalemia (choice D) are not direct signs of digoxin toxicity. Therefore, the correct answer is bradycardia.

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