Nursing Elites

1. After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?

• A. Remove the air from the solution bag
• B. Obtain a piston syringe and irrigation set
• C. Record the solution added as fluid intake
• D. Calculate the rate of flow of the solution

Correct answer: B

Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.

2. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

• A. Ask family members to remain with the client in the evenings from 5 to 8 pm
• B. Administer a prescribed PRN benzodiazepine at the onset of a confused state
• C. Ensure that the client is assigned to a room close to the nurses' station
• D. Postpone administration of nighttime medications until after 11 pm

Correct answer: C

Rationale: Sundowning, a phenomenon where dementia symptoms worsen in the evening, can be managed by ensuring the client is close to the nurses' station for frequent monitoring and quick intervention, if necessary. This reduces the risk of harm and helps manage agitation. Asking family members to remain with the client may not always be feasible and does not address the need for close monitoring. Administering benzodiazepines should not be the first-line intervention for sundowning as it can increase the risk of falls and other adverse effects. Postponing medication administration may disrupt the client's routine and potentially worsen symptoms.

3. You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?

• A. 10
• B. 8
• C. 7
• D. 9

Correct answer: D

Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.

4. A client is recovering from a craniotomy and has a ventriculostomy in place. The nurse notices the drainage from the ventriculostomy is suddenly increasing. What should the nurse do first?

• A. Increase the head of the bed to 45 degrees.
• B. Clamp the ventriculostomy tube.
• C. Notify the healthcare provider immediately.
• D. Measure the client's head circumference.

Correct answer: C

Rationale: A sudden increase in drainage from a ventriculostomy could indicate a serious complication such as increased intracranial pressure or hemorrhage. The priority action in this situation is to notify the healthcare provider immediately to ensure prompt evaluation and intervention. Increasing the head of the bed may be beneficial in some situations but is not the first action to take. Clamping the ventriculostomy tube is inappropriate as it can lead to increased intracranial pressure. Measuring the client's head circumference is not the priority when there is a sudden increase in ventriculostomy drainage.

5. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

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