Nursing Elites

1. While assessing an older client’s fall risk, the client tells the nurse that they live at home alone and have never fallen. What action should the nurse take?

• A. Place the client on a high fall risk protocol solely based on their age
• B. Continue to obtain the client data needed to complete the fall risk survey
• C. Inform the client about falls occurring more often at the hospital than at home
• D. Record a minimal risk for falls based on the client's statement alone

Correct answer: B

Rationale: The correct action for the nurse in this scenario is to continue obtaining client data to complete the fall risk survey. This approach will help in conducting a comprehensive assessment of the client's risk factors. Placing the client on a high fall risk protocol solely based on age without a thorough assessment is premature and can lead to unnecessary interventions. Informing the client about falls in the hospital does not address the client's individual risk factors and is not relevant to the current assessment. Recording a minimal risk for falls based only on the client's statement may overlook other potential risk factors that need to be evaluated.

2. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

• A. Mechanical ventilation
• B. Platelet transfusion
• C. Loop diuretic therapy
• D. Cyanocobalamin administration

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

3. At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement?

• A. Administer insulin based on the sliding scale
• B. Assess the appearance of the foot wound
• C. Obtain antibiotic peak and trough levels
• D. Initiate hourly measurements of urine output

Correct answer: B

Rationale: Assessing the appearance of the foot wound is the priority action in this scenario. This assessment is crucial to monitor for any signs of infection progression or complications related to the foot ulcer, especially in a client with diabetes mellitus. Administering insulin based on the sliding scale (Choice A) is important but not the immediate priority compared to assessing the foot wound. Obtaining antibiotic peak and trough levels (Choice C) is relevant but not as immediate as assessing the wound for signs of infection. Initiating hourly measurements of urine output (Choice D) is not the priority when compared to assessing the foot wound in a client with an infected foot ulcer.

4. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

• A. Evaluate the client for sleep disturbances
• B. limit client exercise
• C. Report any client complaint of pain or discomfort
• D. Note and report the client's food and liquid intake during meals and snacks

Correct answer: D

Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.

5. The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long-term control of diabetes?

• A. The fasting blood sugar was 120 mg/dL this morning
• B. Urine ketones have been negative for the past 6 months
• C. The hemoglobin A1C was 6.5% last week
• D. No diabetic ketoacidosis has occurred in 6 months

Correct answer: C

Rationale: An A1C level of 6.5% indicates good long-term control of diabetes as it reflects the average blood sugar levels over the past 2-3 months. Monitoring fasting blood sugar provides immediate information about the current blood sugar level, while the absence of urine ketones indicates short-term control. Although the absence of diabetic ketoacidosis is positive, it doesn't specifically reflect long-term control like the A1C level does.

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