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. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

• A. The occurrence of any episodes of sleep apnea
• B. The child's blood pressure, pulse, and respirations
• C. Length of rapid eye movement (REM) sleep that the child is experiencing
• D. Description of the family's home environment

Correct answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

3. The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?

• A. Coarse crackles in the lungs.
• B. Fever of 101.2°F (38.4°C).
• C. Productive cough with yellow sputum.
• D. Respiratory rate of 28 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

4. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper, and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

• A. Establish a toileting schedule to decrease episodes of incontinence
• B. Complete a functional assessment of the client’s self-care abilities
• C. Apply a barrier ointment to intact areas that may be exposed to moisture
• D. Determine the size and depth of skin breakdown over the sacral area

Correct answer: D

Rationale: The initial step the nurse should take when faced with skin breakdown over the sacral area of the client is to determine the size and depth of the affected area. Assessing and documenting these aspects are crucial before initiating any treatment. This evaluation will guide the nurse in developing an appropriate care plan to address the skin breakdown effectively. Options A, B, and C are not the first steps to take in this situation. While establishing a toileting schedule and completing a functional assessment are important, assessing the size and depth of the skin breakdown is the priority to initiate proper treatment. Applying a barrier ointment without assessing the extent of the breakdown may not address the underlying issue effectively.

5. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?

• A. I should avoid eating green leafy vegetables.
• B. I should wear loose-fitting clothes to avoid pressure on my legs.
• C. I should avoid prolonged sitting or standing.
• D. I should continue taking my over-the-counter herbal supplements.

Correct answer: D

Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.

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