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 healthcare provider is reviewing the medical record of a client who is scheduled for an abdominal paracentesis. Which of the following actions should the healthcare provider take to prepare the client for this procedure?

• A. Assist the client to void
• B. Instruct the client to hold their breath
• C. Place the client in a lateral recumbent position
• D. Prepare to administer a sedative

Correct answer: A

Rationale: Assisting the client to void before a paracentesis is essential to reduce the risk of bladder injury during the procedure. Voiding helps empty the bladder, preventing accidental puncture during the insertion of the needle. Instructing the client to hold their breath is incorrect and can increase the risk of complications. Placing the client in a lateral recumbent position is not directly related to bladder safety during a paracentesis. Preparing to administer a sedative is not a standard preparation for this procedure and is not aimed at preventing bladder injury.

3. A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. A fasting blood glucose of 90 mg/dL
• B. A blood glucose level of 200 mg/dL
• C. A hemoglobin A1c of 6%
• D. A fasting blood glucose of 100 mg/dL

Correct answer: B

Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.

4. How should a healthcare provider manage a patient with hyperkalemia?

• A. Administer insulin and glucose
• B. Restrict potassium intake
• C. Monitor ECG
• D. All of the above

Correct answer: D

Rationale: In managing hyperkalemia, it is essential to administer insulin and glucose to shift potassium into the cells, restrict potassium intake to prevent further elevation of serum levels, and monitor the ECG for signs of potassium-induced cardiac effects. Therefore, the correct answer is D, as all of the provided actions are important in the management of hyperkalemia. Choice A alone is not sufficient as it only addresses shifting potassium intracellularly without preventing further elevation. Choice B alone is not enough as it does not address the immediate need to lower serum potassium levels. Choice C alone is insufficient as it only monitors for cardiac effects without addressing potassium levels or shifting mechanisms.

5. Which intervention is most important for a client with chronic heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit sodium intake to reduce fluid retention
• D. Restrict daily activity to prevent fatigue

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with chronic heart failure. Monitoring weight helps in detecting fluid retention or fluid loss, which is crucial in managing heart failure. Encouraging fluid intake to prevent dehydration (choice A) may worsen fluid overload in heart failure patients. Limiting sodium intake (choice C) is essential but not the most important intervention compared to monitoring weight. Restricting daily activity (choice D) is not recommended as it is important for clients with heart failure to engage in appropriate levels of physical activity to maintain their overall health.

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