Nursing Elites

1. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?

• A. Facilitate the client in returning to usual activities of daily living
• B. Maintain optimal function within the client's limitations
• C. Assist the client in preparing for a peaceful and dignified death
• D. Delay the progression of the disease process in the client

Correct answer: B

Rationale: Maintaining optimal function within the client's limitations is the most realistic and appropriate nursing goal when caring for an 80-year-old client with Parkinson's disease. This goal focuses on maximizing the client's abilities and quality of life while acknowledging the impact of the disease. Option A is less realistic as returning to usual activities may not always be achievable in the case of Parkinson's disease. Option C is not appropriate as it does not address the client's current condition and care needs. Option D is less realistic as Parkinson's disease is progressive, and delaying its progression may not be entirely feasible.

2. What is the priority for the nurse when caring for a patient with a chest tube?

• A. Ensure tube patency and observe for air leaks
• B. Maintain sterile technique during dressing changes
• C. Monitor drainage and record output
• D. Observe for signs of infection and monitor for subcutaneous emphysema

Correct answer: A

Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.

3. When should a healthcare provider suction a client's tracheostomy?

• A. When the client is hypotensive
• B. When the client is irritable
• C. When the client is flushed
• D. When the client is bradycardic

Correct answer: B

Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.

4. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

• A. Paradoxical excitement
• B. Headache
• C. Slowing of reflexes
• D. Fatigue

Correct answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

5. What is the recommended intervention for a patient experiencing severe hypoglycemia?

• A. Administer glucagon
• B. Provide a source of glucose
• C. Monitor blood sugar
• D. Assess vital signs

Correct answer: A

Rationale: Administering glucagon is the recommended intervention for severe hypoglycemia, especially when the patient is unconscious or unable to consume oral glucose. Glucagon helps increase blood glucose levels rapidly by stimulating the release of stored glucose from the liver. Providing a source of glucose (Choice B) can be challenging if the patient is unable to swallow or unconscious, making glucagon a more effective option. Monitoring blood sugar levels (Choice C) and assessing vital signs (Choice D) are important aspects of managing hypoglycemia but are not the immediate intervention for severe cases where prompt elevation of blood glucose levels is necessary.

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