Nursing Elites

1. During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?

• A. provide the client with 4 ounces of orange juice
• B. call 911 to summon emergency assistance
• C. check the client for lacerations or fractures
• D. assess the client's blood sugar level

Correct answer: C

Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.

2. When developing a program to support caregivers of elderly patients, which topic should be prioritized in the first session?

• A. Managing medication schedules
• B. Recognizing signs of caregiver burnout
• C. Effective communication with healthcare providers
• D. Navigating insurance and financial issues

Correct answer: B

Rationale: Recognizing signs of caregiver burnout is the most critical topic to prioritize in the first session. Caregiver burnout can have detrimental effects on both the caregiver and the elderly patient's well-being. By addressing this issue early on, caregivers can learn to identify the signs of burnout, take necessary steps to prevent it, and ensure they can continue providing effective care for their loved ones. Managing medication schedules, effective communication with healthcare providers, and navigating insurance and financial issues are also important aspects to cover in the program. However, recognizing signs of caregiver burnout is essential for the overall health and quality of care provided by the caregivers.

3. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which assessment finding requires immediate intervention?

• A. Amylase of 120 U/L.
• B. Lipase of 150 U/L.
• C. Calcium of 8.5 mg/dL.
• D. Temperature of 101°F (38.3°C).

Correct answer: D

Rationale: In a client with acute pancreatitis and a history of alcohol abuse, a temperature of 101°F (38.3°C) can indicate infection, which is a serious complication requiring immediate intervention. Elevated amylase and lipase levels are common in acute pancreatitis but do not directly indicate the need for urgent intervention. A calcium level of 8.5 mg/dL is within the normal range and does not require immediate action in this context.

4. A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?

• A. Continue the heparin infusion as prescribed.
• B. Decrease the heparin infusion rate.
• C. Increase the heparin infusion rate.
• D. Stop the heparin infusion and notify the healthcare provider.

Correct answer: D

Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.

5. The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?

• A. The client's respiratory rate is 20 breaths per minute.
• B. The client's arterial blood gases show a pH of 7.35.
• C. The client's oxygen saturation is 92%.
• D. The client's breath sounds are clear.

Correct answer: A

Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.

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