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. A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client’s respiratory function?

• A. Arterial blood gases (ABGs)
• B. Complete blood count (CBC)
• C. Blood glucose levels
• D. Serum electrolyte levels

Correct answer: A

Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.

3. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?

• A. Take measures to promote as much comfort as possible.
• B. Report any signs of drug addiction to the nurse immediately.
• C. Wait until the client's pain is gone before assisting with personal care.
• D. This client's pain will be difficult to manage, as the cause is unknown.

Correct answer: A

Rationale: The correct instruction for the unlicensed assistive personnel (UAP) preparing to assist a client with intractable pain is to take measures to promote as much comfort as possible. Intractable pain is resistant to relief, so ensuring comfort during all activities, including a bed bath, is crucial to enhance the client's well-being and quality of care.

4. The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

• A. Performing ROM exercises during bathing.
• B. Changing the patient's position every two hours.
• C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
• D. Placing the patient in the prone position for one hour three times a day.

Correct answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

5. A client with a history of myocardial infarction (MI) is admitted with chest pain. Which laboratory test should the nurse expect to be ordered to determine if the client is experiencing another MI?

• A. Troponin
• B. Myoglobin
• C. CK-MB
• D. C-reactive protein

Correct answer: A

Rationale: Troponin is the most specific and sensitive laboratory test for detecting myocardial infarction (MI). It is released when there is damage to the heart muscle, making it a valuable marker for diagnosing another MI. Myoglobin and CK-MB can also be elevated in MI, but troponin is preferred due to its higher specificity. C-reactive protein is a marker of inflammation and not specific to MI.

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