Nursing Elites

1. During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, 'She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore.' Which suggestions should the nurse make to the daughter?

• A. Ask the client's physician for a strong sleep medicine
• B. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime
• C. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day
• D. Promote relaxation before bedtime with a warm bath or relaxing music

Correct answer: B

Rationale: The correct answer is to establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. By creating a structured daily schedule, the client's natural sleep-wake cycle can be regulated, helping to address the issue of daytime sleeping and nighttime wakefulness. Option A, asking for a strong sleep medicine, may not address the underlying cause and can have potential side effects in the elderly. Option C, engaging in exercises when drowsy, may not be suitable for someone with dementia and could disrupt sleep patterns further. Option D, promoting relaxation before bedtime, is helpful but may not be sufficient to address the client's significant sleep issue.

2. A client is constipated and asks the nurse for advice. What should the nurse recommend?

• A. Administer a laxative to relieve discomfort
• B. Increase dietary fiber to promote bowel movements
• C. Advise the client to rest until symptoms resolve
• D. Encourage bed rest to allow bowel function to return

Correct answer: B

Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.

3. What are the principles of aseptic technique in wound care?

• A. Use sterile gloves and a clean dressing
• B. Apply a clean dressing using sterile scissors
• C. Wash hands thoroughly before applying the dressing
• D. Use a clean glove and avoid contact with the wound

Correct answer: A

Rationale: The correct answer is A: 'Use sterile gloves and a clean dressing.' Aseptic technique in wound care requires the use of sterile gloves to prevent infection. Choice B is incorrect as the method of application does not primarily focus on maintaining asepsis. Choice C, while important for infection control, is not specific to aseptic technique in wound care. Choice D is incorrect because using a single clean glove does not ensure the level of sterility needed for aseptic wound care.

4. A nurse is reviewing the plan of care for a client who is undergoing total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor the client's electrolyte levels daily
• B. Weigh the client daily
• C. Monitor the client's blood glucose levels every 6 hours
• D. Change the TPN tubing every 24 hours

Correct answer: D

Rationale: The correct intervention for the nurse to include in the plan of care for a client undergoing total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. Changing the tubing at regular intervals helps reduce the risk of infection associated with central venous catheters. Monitoring electrolyte levels daily (Choice A) is important but not specific to TPN. Weighing the client daily (Choice B) is important for monitoring fluid status but not directly related to TPN. Monitoring blood glucose levels every 6 hours (Choice C) is essential for clients receiving TPN, but changing the tubing is a more critical intervention to prevent infections.

5. What should a healthcare professional assess in a patient presenting with symptoms of a stroke?

• A. Assess facial drooping
• B. Monitor speech difficulties
• C. Evaluate arm weakness
• D. Check for time of onset of symptoms

Correct answer: A

Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.

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