Nursing Elites

1. What should be done to minimize the risk of injury for a client with dementia?

• A. Ensure the client has consistent caregivers
• B. Dim the lights in the client's room
• C. Allow the client to sleep with the bedrails raised
• D. Encourage family members to stay with the client

Correct answer: A

Rationale: The correct answer is to ensure the client has consistent caregivers. This helps reduce confusion and stress for clients with dementia by providing familiarity and routine. Dimming the lights in the client's room (Choice B) may not directly address the risk of injury. Allowing the client to sleep with the bedrails raised (Choice C) can pose a risk if not properly monitored. Encouraging family members to stay with the client (Choice D) may not always be feasible and may not provide the necessary professional support and consistency that consistent caregivers can offer.

2. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

• A. Canned soup
• B. Grilled chicken
• C. Peanut butter
• D. Orange juice

Correct answer: B

Rationale: Grilled chicken is the correct choice as it is a low-potassium, low-sodium option suitable for clients with chronic kidney disease. Canned soup (choice A) is typically high in sodium, which is not recommended for this client population. Peanut butter (choice C) is high in potassium and phosphorus, which should be limited in individuals with kidney disease. Orange juice (choice D) is high in potassium and should be consumed in moderation by clients with chronic kidney disease.

3. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

4. A nurse is reviewing the medical record of a client who is receiving warfarin for atrial fibrillation. Which of the following findings should the nurse report to the provider?

• A. International normalized ratio (INR) of 2.5
• B. Platelet count of 180,000/mm³
• C. Prothrombin time (PT) of 12 seconds
• D. Partial thromboplastin time (PTT) of 30 seconds

Correct answer: C

Rationale: A prothrombin time (PT) of 12 seconds is below the therapeutic range for warfarin and indicates a need for dosage adjustment. The correct answer is C. A normal International normalized ratio (INR) for a client on warfarin therapy is usually between 2.0 to 3.0; therefore, an INR of 2.5 is within the expected range. A platelet count of 180,000/mm³ is within the normal range (150,000 to 450,000/mm³) and does not require immediate reporting. A partial thromboplastin time (PTT) of 30 seconds is also within the normal range (25-35 seconds) and does not indicate a need for urgent action.

5. A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

• A. Remove the weights
• B. Ensure the weights hang freely
• C. Increase the traction force
• D. Loosen the ropes

Correct answer: B

Rationale: The correct action the nurse should take when caring for a client in Buck's traction is to ensure the weights hang freely. This is essential to maintain proper alignment and ensure the effectiveness of Buck's traction. Removing the weights (Choice A) would be incorrect and could compromise the treatment. Increasing the traction force (Choice C) can lead to excessive pressure and potential harm to the client. Loosening the ropes (Choice D) would also be inappropriate as it can disrupt the traction's effectiveness and alignment.

Similar Questions