Nursing Elites

1. A nurse is reviewing the record of a client with dementia. Which of the following findings should the nurse prioritize?

• A. Wandering at night
• B. A serum albumin level of 3.5 g/dL
• C. Urinary incontinence
• D. Restlessness and agitation

Correct answer: D

Rationale: Restlessness and agitation in clients with dementia could indicate a worsening condition and should be prioritized. While wandering at night and urinary incontinence are common issues in dementia patients, restlessness and agitation can signal acute distress or an unmet need, requiring immediate attention. Monitoring serum albumin levels is important for overall health but would not be the priority when assessing a client with dementia.

2. A client is learning about preventing hip dislocation before total hip arthroplasty. Which instruction should be included?

• A. Avoid bending the hip more than 90 degrees
• B. Avoid lying on the unaffected side
• C. Avoid crossing the legs at the knees
• D. Avoid keeping the legs in a neutral position

Correct answer: C

Rationale: The correct instruction to prevent hip dislocation after total hip arthroplasty is to avoid crossing the legs at the knees. This position can put stress on the hip joint and increase the risk of dislocation. Choices A, B, and D are incorrect. Bending the hip more than 90 degrees, lying on the unaffected side, or keeping the legs in a neutral position are not directly related to preventing hip dislocation in this context.

3. Which intervention is most important for a client with rheumatoid arthritis?

• A. Massage inflamed joints with creams and oils
• B. Provide support to flexed joints with pillows and pads
• C. Position the client on their abdomen several times a day
• D. Assist with heat application and range of motion exercises

Correct answer: D

Rationale: The most important intervention for a client with rheumatoid arthritis is to assist with heat application and range of motion exercises. Heat application helps reduce stiffness and improve joint flexibility, while range of motion exercises help maintain mobility and prevent contractures. Massaging inflamed joints with creams and oils may provide temporary relief but does not address the root cause of stiffness and limited mobility in rheumatoid arthritis. Providing support to flexed joints with pillows and pads can be helpful for comfort but does not actively promote mobility. Positioning the client on their abdomen several times a day is not a standard intervention for managing rheumatoid arthritis.

4. What is an important consideration when administering a blood transfusion?

• A. Ensure the blood is compatible with the recipient's blood type
• B. Warm the blood to body temperature before administration
• C. Check the blood for clots before administration
• D. Ensure the recipient eats before the transfusion

Correct answer: A

Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.

5. Which instruction is crucial for a client with diabetes being discharged?

• A. Take insulin only when feeling unwell
• B. Administer insulin before meals as prescribed
• C. Monitor blood sugar levels weekly
• D. Check blood sugar once in the morning

Correct answer: B

Rationale: Administering insulin before meals as prescribed is crucial for a client with diabetes being discharged because it ensures proper blood sugar control. Choice A is incorrect because insulin should not be taken only when feeling unwell; it should be taken as prescribed. Choice C is incorrect as monitoring blood sugar levels weekly may not provide timely adjustments to insulin doses. Choice D is incorrect as checking blood sugar only once in the morning is not sufficient for proper diabetes management.

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