Nursing Elites

1. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.

2. During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

• A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
• B. The client tells the nurse that she does not have much of an appetite today.
• C. The nurse notes that there are numerous scatter rugs throughout the house.
• D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

3. A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?

• A. Encourage the client to use sunscreen when outdoors.
• B. Apply a heating pad to the radiation site.
• C. Instruct the client to avoid using deodorant on the skin near the radiation site.
• D. Advise the client to increase intake of green leafy vegetables.

Correct answer: C

Rationale: Instructing the client to avoid using deodorant on the skin near the radiation site (C) is crucial to prevent skin irritation and potential adverse reactions during external radiation therapy. Sunscreen (A), heating pad (B), and dietary changes (D) are less pertinent in this situation.

4. A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?

• A. Regular insulin
• B. NPH insulin
• C. Lispro insulin
• D. Glargine insulin

Correct answer: A

Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.

5. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

• A. Position the client supine for a few minutes
• B. Assist the client to stand at the bedside
• C. Apply the blood pressure cuff securely
• D. Record the client’s pulse rate and rhythm

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

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