Nursing Elites

1. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply)

• A. Decrease laxative use to every other day and use oil retention enemas as needed.
• B. Include oatmeal with stewed prunes for breakfast as often as possible.
• C. Increase fluid intake by keeping a water glass next to the recliner.
• D. Recommend seeking help with regular shopping and meal preparation.

Correct answer: C

Rationale: The correct answer is C. Increasing fluid intake is essential for managing constipation. Adequate hydration helps soften stool and promotes bowel movements. Choices A and B are incorrect as decreasing laxative use without medical advice and suggesting specific foods like oatmeal with stewed prunes may not be suitable for every individual with constipation. Choice D is also incorrect as while seeking help with meal preparation can indirectly aid in managing constipation, the immediate need is to increase fluid intake.

2. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

3. The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?

• A. Continue to measure the client’s vital signs every thirty minutes until the transfusion is complete
• B. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
• C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately
• D. Notify the nurse when the transfusion has finished, so further client assessment can be done

Correct answer: A

Rationale: The correct instruction for the UAP is to continue measuring the client’s vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.

4. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Stroke secondary to hemorrhage
• B. Acute kidney injury due to glomerular damage
• C. Heart block due to myocardial damage
• D. Blindness secondary to cataracts

Correct answer: A

Rationale: The correct answer is A: Stroke secondary to hemorrhage. Hypertension increases the risk of stroke due to the stress and damage it causes to blood vessels, which can lead to hemorrhage. Choice B is incorrect because acute kidney injury is more commonly associated with chronic uncontrolled hypertension, not acute elevations. Choice C is incorrect as heart block is not a direct consequence of hypertension. Choice D is incorrect as hypertension does not directly cause cataracts leading to blindness.

5. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?

• A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
• B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
• C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
• D. Encourage the client to avoid becoming involved in the neighbor’s problems for one’s protection.

Correct answer: C

Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.

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