Nursing Elites

1. When working with elderly clients, the healthcare provider should keep in mind that falls are most likely to happen to the elderly who are:

• A. in their 80s.
• B. living at home.
• C. hospitalized.
• D. living on only Social Security income.

Correct answer: C

Rationale: The correct answer is 'hospitalized.' Elderly individuals are at a higher risk of falls, especially when they are in new environments like hospitals due to unfamiliarity with the surroundings, medications, and potential mobility challenges. Being in a hospital can disrupt their usual routines and increase the risk of falls. Choice A ('in their 80s') is not as directly related to the increased risk of falls in a hospital environment. Choice B ('living at home') is a common setting for the elderly but does not address the specific risk associated with being hospitalized. Choice D ('living on only Social Security income') is unrelated to the risk of falls based on the environment.

2. Which of the following statements from a client may indicate that they are at a higher risk for a fall?

• A. "I would like to get out of bed but would like to put on my non-skid socks first."?
• B. "Can you make sure the two bedrails are raised before leaving the room?"?
• C. "I think I'm ready to walk a longer distance with the cane today."?
• D. "I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait."?

Correct answer: D

Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.

3. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. Increase maternal fluids.
• B. Administer oxygen.
• C. Decrease maternal fluids.
• D. Turn the mother.

Correct answer: C

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.

4. An LPN is caring for a primarily bedridden client. Which finding should be of least concern?

• A. swollen feet
• B. brown discoloration above the ankles
• C. leg pain
• D. capillary refill time of 3 seconds on the big toe

Correct answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.

5. A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO®. How many milliliters of fluid did the patient ingest?

• A. 440 ml
• B. 480 ml
• C. 220 ml
• D. 660 ml

Correct answer: B

Rationale: To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO® (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO®) = 480 ml. Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids. Choice A, 440 ml, is incorrect as it does not account for the correct calculation. Choice C, 220 ml, is incorrect as it is significantly lower than the correct total. Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.

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