Nursing Elites

1. When reviewing the medical record of a client with dementia, what should the nurse prioritize addressing?

• A. Mild confusion in the morning
• B. Restlessness and agitation
• C. Incontinence
• D. Frequent wandering at night

Correct answer: B

Rationale: When caring for clients with dementia, addressing restlessness and agitation is a priority as it can lead to distress, safety risks, and potential harm to the client or others. Restlessness and agitation are common behavioral symptoms of dementia and can indicate unmet needs, discomfort, or confusion. Managing these symptoms promptly can help improve the client's quality of life and prevent complications such as falls, injuries, or escalation of challenging behaviors. While other issues like mild confusion, incontinence, and wandering are also important to address, managing restlessness and agitation takes precedence due to its immediate impact on the client's well-being and safety.

2. A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?

• A. White blood cell count of 8,000/mm³
• B. Potassium level of 4.0 mEq/L
• C. Creatinine level of 1.0 mg/dL
• D. Hemoglobin level of 12 g/dL

Correct answer: C

Rationale: An elevated creatinine level indicates impaired kidney function, which may affect the client's ability to undergo surgery. The other laboratory values (white blood cell count, potassium level, and hemoglobin level) are within normal ranges and do not directly impact the client's readiness for surgery.

3. When caring for a client with a wound infection, what should the nurse prioritize?

• A. Change the dressing daily
• B. Cleanse the wound with an antiseptic solution
• C. Apply a wet-to-dry dressing to the wound
• D. Perform a wound culture before administering antibiotics

Correct answer: D

Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.

4. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

5. A client who has a new prosthesis for an above-the-knee amputation of the right leg needs teaching on its use. Which of the following instructions should the nurse include?

• A. Wear the prosthesis for 2 hours at a time
• B. Remove the prosthesis every other day
• C. Apply the prosthesis immediately upon waking each day
• D. Elevate the stump for 24 hours after applying the prosthesis

Correct answer: C

Rationale: The correct instruction is to apply the prosthesis immediately upon waking each day. This helps the client adjust to and maintain mobility. Choice A is incorrect because wearing the prosthesis for only 2 hours at a time may not be sufficient for proper adjustment. Choice B is incorrect as removing the prosthesis every other day is not a standard practice and may hinder the client's mobility. Choice D is incorrect because elevating the stump for 24 hours after applying the prosthesis is unnecessary and not a recommended practice.

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