Nursing Elites

1. Which of the following interventions should the nurse implement for a client with dementia who is at risk of falling?

• A. Keep the bed in the lowest position
• B. Raise all four side rails to prevent falls
• C. Assist with ambulation every 2 hours
• D. Use a bed exit alarm to notify staff of attempts to leave the bed

Correct answer: D

Rationale: The correct intervention for a client with dementia at risk of falling is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention helps in preventing falls by alerting the staff when the client tries to get out of bed. Keeping the bed in the lowest position (Choice A) may not prevent falls and could make it challenging for staff to provide care. Raising all four side rails (Choice B) can be a restraint and is not recommended as it may lead to entrapment or other risks. Assisting with ambulation every 2 hours (Choice C) may not be feasible or effective in preventing falls, as the client may attempt to get out of bed at any time.

2. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?

• A. Use the cane on the weak side of the body
• B. Advance the cane and the strong leg simultaneously
• C. Maintain two points of support on the floor
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: C

Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

3. A client who is to undergo surgery for a hip fracture is being taught by a nurse about postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will ask for pain medication only if the pain becomes unbearable.
• B. I will ask the nurse to increase my medication if the pain doesn't subside.
• C. I will wait until the pain is severe before taking my medication.
• D. I will take my medication at regular intervals to stay ahead of the pain.

Correct answer: D

Rationale: The correct answer is D because taking pain medication at regular intervals helps maintain consistent pain control after surgery. Option A is incorrect because waiting for the pain to become unbearable can lead to inadequate pain management. Option B is incorrect as it suggests increasing medication without a schedule. Option C is incorrect because waiting for the pain to be severe before taking medication is not proactive pain management.

4. A client is using a metered-dose inhaler (MDI) for asthma management. Which of the following actions by the client indicates an understanding of the teaching?

• A. Inhale rapidly through the mouth after pressing down on the inhaler
• B. Exhale completely before pressing down on the inhaler
• C. Hold your breath for 5-10 seconds after inhaling
• D. Inhale slowly while pressing down on the inhaler

Correct answer: C

Rationale: The correct answer is to hold your breath for 5-10 seconds after inhaling when using a metered-dose inhaler (MDI) for asthma management. This action ensures proper medication absorption in the lungs. Inhaling rapidly (choice A) may cause the medication to impact the mouth/throat rather than the lungs. Exhaling completely before inhalation (choice B) does not optimize medication delivery. Inhaling slowly (choice D) may not allow the medication to reach the lungs effectively.

5. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

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