Nursing Elites

1. The wife of an older adult man who has had diabetes mellitus for the past 10 years reports to the home health nurse that her husband fell yesterday while taking his daily walk in the neighborhood. He has a bruised hand and a small abrasion on his left knee. The nurse assesses that his neurologic vital signs are stable. To reduce the risk for future falls, which assessment is most important for the nurse to obtain?

• A. current blood sugar level
• B. degree of paresthesia in feet
• C. wound healing of knee abrasion
• D. A1c glycosylated hemoglobin

Correct answer: B

Rationale: Assessing for paresthesia (numbness or tingling) in the feet is crucial in this scenario as it can help determine if the client has a loss of sensation, which increases the risk of falls. Paresthesia is a common complication of diabetes that can lead to decreased sensation and proprioception in the feet, contributing to balance issues and an increased risk of falls. Monitoring for paresthesia allows the nurse to assess the extent of sensory impairment and implement appropriate interventions to prevent future falls. While monitoring blood sugar levels (choice A) and A1c levels (choice D) are important in managing diabetes, in this case, assessing paresthesia takes precedence due to its direct impact on fall risk. Similarly, while monitoring the wound healing of the knee abrasion (choice C) is important for overall wound care, it is not directly related to reducing the risk of future falls in this situation.

2. A client who is receiving total parenteral nutrition (TPN) has an elevated blood glucose level. Which action should the nurse take first?

• A. Stop the TPN infusion.
• B. Administer insulin as prescribed.
• C. Notify the healthcare provider.
• D. Check the TPN infusion rate.

Correct answer: D

Rationale: The correct first action for a client receiving TPN with an elevated blood glucose level is to check the TPN infusion rate. Elevated blood glucose levels in clients receiving TPN can be due to incorrect infusion rates leading to increased glucose delivery. By checking the TPN infusion rate, the nurse can verify if the rate is appropriate and make necessary adjustments. Stopping the TPN infusion abruptly could lead to complications from sudden nutrient deprivation. Administering insulin as prescribed may be necessary but should come after ensuring the correct TPN infusion rate. Notifying the healthcare provider is important but addressing the immediate need to check the infusion rate takes priority to manage hyperglycemia effectively.

3. The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?

• A. Muscle weakness.
• B. Irregular heart rate.
• C. Increased urinary output.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.

4. The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?

• A. Weight gain of 1 pound.
• B. Dizziness.
• C. Fatigue.
• D. Muscle cramps.

Correct answer: D

Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.

5. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?

• A. Check the client's vital signs before starting the transfusion.
• B. Use a blood filter when administering the transfusion.
• C. Verify the blood type and Rh factor with another healthcare professional.
• D. Administer antihistamines before starting the transfusion.

Correct answer: C

Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.

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