Nursing Elites

1. The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?

• A. Question the client about the frequency of falls.
• B. Request the client to lie still during the assessment.
• C. Ask how often episodes of sundowning are experienced.
• D. Assist the client with values clarification about end-of-life care.

Correct answer: A

Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.

2. A client has been given a prescription for tetracycline HCL (Sumycin). The nurse should emphasize the client to

• A. Take the medication with food or milk
• B. Avoid prolonged sun exposure
• C. Monitor for signs of yellowing skin or eyes
• D. Expect a yellow-brown discoloration of the teeth

Correct answer: C

Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.

3. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Administer an antihistamine as prescribed.
• C. Administer a dose of acetaminophen.
• D. Administer a PRN dose of diphenhydramine.

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

4. A client with rheumatoid arthritis is prescribed methotrexate. What is the most important teaching point for the nurse to provide?

• A. Take the medication with food to avoid gastrointestinal upset.
• B. Monitor for signs of infection, such as a sore throat.
• C. Increase fluid intake to prevent dehydration.
• D. Avoid direct sunlight to prevent photosensitivity.

Correct answer: D

Rationale: The most important teaching point for a client prescribed methotrexate is to avoid direct sunlight to prevent photosensitivity. Methotrexate can make the skin more sensitive to sunlight, increasing the risk of sunburn and skin damage. Choices A, B, and C are important aspects of client care but are not specifically related to the side effect of photosensitivity caused by methotrexate.

5. A client is experiencing chest pain and is prescribed nitroglycerin. What should the nurse assess before administering the medication?

• A. Monitor the client’s oxygen saturation level.
• B. Check the client’s heart rate and blood pressure.
• C. Evaluate the client’s level of consciousness.
• D. Assess the client's chest pain severity using a pain scale.

Correct answer: B

Rationale: Before administering nitroglycerin, it is crucial to check the client’s heart rate and blood pressure. Nitroglycerin can lower blood pressure and heart rate, so assessing these parameters is essential to prevent exacerbating hypotension or bradycardia. While monitoring the client’s oxygen saturation level is important in some situations, it is not the primary assessment needed before administering nitroglycerin. Evaluating the client’s level of consciousness is relevant for other conditions but not specifically necessary before giving nitroglycerin. Assessing chest pain severity using a pain scale is valuable for pain management but is not the priority assessment before administering nitroglycerin.

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