Nursing Elites

1. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

• A. The client should remove all scatter rugs from the floor and minimize clutter.
• B. The client should not limit her movement within the home unless advised by the physician.
• C. The client should have a raised toilet seat and grab bars available in the bathroom.
• D. The client should not wear a robe and socks while walking in the house.

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

2. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetes Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.

3. The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?

• A. 100 mL/hr
• B. 150 mL/hr
• C. 200 mL/hr
• D. 50 mL/hr

Correct answer: A

Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.

4. In a community pediatric health clinic, which developmental task should you apply into your practice?

• A. You should apply the principles of initiative when caring for preschool children.
• B. You should apply the principles of sensorimotor thought when caring for preschool children.
• C. You should apply the principles of intimacy when caring for the adolescent.
• D. You should apply the principles of concrete operations when caring for the adolescent.

Correct answer: A

Rationale: When working in a community pediatric health clinic, applying the principles of initiative is crucial when caring for preschool children. According to Erik Erikson's psychosocial theory, the developmental task for preschool children is initiative. Preschool children are in the stage where they are eager to initiate activities and carry out tasks. This stage is characterized by a balance between initiative and guilt. By encouraging children to explore and take the initiative in a supportive environment, healthcare providers can foster their sense of independence and creativity. The other choices are incorrect because: - Sensorimotor thought is a term associated with Jean Piaget's cognitive development theory, not Erikson's psychosocial theory. - Intimacy is a developmental task associated with young adults, not adolescents, in Erikson's theory. - Concrete operations is a term linked to Piaget's theory of cognitive development and is not a developmental task according to Erikson's psychosocial theory.

5. A laboring client is experiencing late decelerations. Which position should she be placed in?

• A. left lateral
• B. lithotomy
• C. semi-Fowler's
• D. right lateral

Correct answer: A

Rationale: The correct answer is the left lateral position. Placing the laboring client in the left lateral position is beneficial because it promotes blood flow to the placenta. Late decelerations indicate potential issues with fetal oxygenation, and changing the position to left lateral can help improve placental perfusion. Choices B, C, and D are incorrect because lithotomy, semi-Fowler's, and right lateral positions do not specifically address the need for improved blood flow to the placenta in cases of late decelerations.

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