Nursing Elites

1. The nurse is caring for an older adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment, the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?

• A. These are normal signs of aging.
• B. These are early signs of dementia.
• C. These are purely psychological in origin.
• D. These are common manifestations with UTIs.

Correct answer: D

Rationale: The nurse should interpret confusion and agitation in an older adult patient with a UTI as common manifestations of the infection. In older patients, confusion is a primary symptom of a compromised state due to an acute urinary tract infection or fever. Choice A is incorrect as confusion and agitation are not normal signs of aging. Choice B is incorrect because these symptoms are more likely related to the UTI rather than early signs of dementia. Choice C is incorrect as confusion and agitation in this context are not purely psychological but are likely physiological responses to the UTI.

2. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glascow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glascow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.

3. A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?

• A. Use the planning step of the nursing process to prioritize client care delivery.
• B. Delegate all tasks to assistive personnel.
• C. Focus on completing tasks in the order they are assigned.
• D. Avoid using a checklist for daily tasks.

Correct answer: A

Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.

4. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

• A. Check to see if the tubing is kinked.
• B. Increase the IV fluid rate.
• C. Check the catheter insertion site.
• D. Contact the healthcare provider.

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

5. A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?

• A. Slower light touch sensation
• B. Some vision and hearing decline
• C. Slower fine finger movement
• D. Some short-term memory decline

Correct answer: B

Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.

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