Nursing Elites

1. An older client comes to the clinic with a family member. When the nurse attempts to take the client’s health history, the client does not respond to questions clearly. What action should the nurse implement first?

• A. Assess the surroundings for noise and distractions
• B. Provide a printed health history form
• C. Defer the health history until the client is less anxious
• D. Ask the family member to answer the questions

Correct answer: A

Rationale: The correct action for the nurse to implement first is to assess the surroundings for noise and distractions. This step is crucial as environmental factors can affect the client's ability to respond clearly. By minimizing noise and distractions, the nurse can create a more conducive environment for effective communication. Providing a printed form (Choice B) may help but addressing environmental factors should come first. Deferring the health history (Choice C) or asking the family member to answer the questions (Choice D) should not be the initial steps, as they do not directly address the issue of unclear communication with the client.

2. What should the nurse monitor for during the IV infusion of vasopressin (Pitressin) in a client with bleeding esophageal varices?

• A. Vasodilatation of the extremities
• B. Chest pain and dysrhythmia
• C. Hypotension and tachycardia
• D. Decreasing GI cramping and nausea

Correct answer: B

Rationale: During the IV infusion of vasopressin in a client with bleeding esophageal varices, the nurse should monitor for chest pain and dysrhythmia. Vasopressin is a vasoconstrictor that can cause cardiovascular effects, including chest pain and dysrhythmias. Options A, C, and D are incorrect as vasopressin is not expected to cause vasodilatation of the extremities, hypotension, tachycardia, or improvements in GI symptoms such as cramping and nausea.

3. When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?

• A. The presence and location of any pressure ulcers.
• B. Measures already taken to maintain client safety.
• C. Any special mattresses on the client’s bed.
• D. Current vital signs and oxygen saturation.

Correct answer: B

Rationale: The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.

4. The client who had a below-the-knee (BKA) amputation is being prepared for discharge to home. Which recommendation should the nurse provide this client?

• A. Inspect skin for redness
• B. Use a residual limb shrinker
• C. Apply alcohol to the stump after bathing
• D. Wash the stump with soap and water

Correct answer: D

Rationale: The correct recommendation for a client with a below-the-knee amputation preparing for discharge is to wash the stump with soap and water. This helps maintain cleanliness and prevent infection. Inspecting the skin for redness is important to monitor for signs of infection, but it is not a specific recommendation for a BKA amputation. Using a residual limb shrinker can aid in shaping and reducing swelling in the residual limb but is not usually done immediately after a BKA amputation. Applying alcohol to the stump after bathing is not recommended as it can lead to skin irritation and dryness.

5. The urinary drainage of a client with continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement?

• A. Increase the irrigation rate
• B. Lower the head of the bed
• C. Milk the catheter tubing
• D. Evaluate for fluid overload

Correct answer: A

Rationale: Increasing the irrigation rate can help clear any blood clots and reduce the redness in the urinary drainage. This intervention aims to improve the flushing of the bladder and potentially resolve the issue. Lowering the head of the bed would not directly address the red urinary drainage. Milking the catheter tubing is not recommended as it can cause trauma to the catheter or bladder, leading to further complications. While evaluating for fluid overload is an important nursing consideration, it does not directly address the immediate concern of redness in the urinary drainage, which requires a focused intervention to clear any blockages or clots in the system.

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