Nursing Elites

1. Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client’s plan of care?

• A. Recent serum hemoglobin level of 16 g/dL
• B. Opioid analgesic received one hour ago
• C. Stooped posture with an unsteady gait
• D. Expressed feelings of depression

Correct answer: B

Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

2. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?

• A. Assess the client for confusion and reteach the procedure
• B. Check the urine for color and texture
• C. Empty the urinal contents into the 24-hour collection container
• D. Discard the contents of the urinal

Correct answer: C

Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.

3. At 0100 on a male client’s second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Leave the room and close the door to the client’s room
• B. Assess the appearance of the client’s surgical dressing
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Discuss symptoms of sleep deprivation with the client

Correct answer: A

Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.

4. The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?

• A. Notify the surgical team of the client’s confusion
• B. Have the client sign a new surgical consent
• C. Add the correct leg information to the consent form
• D. Inform the surgeon about the client’s concern

Correct answer: D

Rationale: In this scenario, the nurse should inform the surgeon about the client’s concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.

5. While the nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia and reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?

• A. Instruct the client to repeat the medication plan
• B. Encourage the client to take a PRN antianxiety drug
• C. Provide written instructions that are easy to follow
• D. Include a family member in the teaching session

Correct answer: A

Rationale: In this situation, the most important action for the nurse to implement is to instruct the client to repeat the medication plan. By using the teach-back method, the nurse can ensure the client's understanding of the prescribed medications and address any concerns or anxieties the client may have. This approach promotes patient engagement, active participation, and retention of important information, ultimately enhancing medication adherence and safety.

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