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. The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understands the instruction?

• A. Aspirates the newborn’s nares using a syringe
• B. Applies a dressing to the cord after the newborn’s bath
• C. Breastfeeds the infant every hour during the night
• D. Positions the infant supine in the crib to sleep

Correct answer: D

Rationale: Positioning the infant supine in the crib to sleep is the correct action that indicates the mother understands the instruction. This position is recommended to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice A is incorrect as it is not a routine or recommended practice to aspirate the newborn’s nares using a syringe without a specific medical indication. Choice B is incorrect because applying a dressing to the cord after the newborn's bath is not a standard care practice. Choice C is incorrect because breastfeeding every hour during the night is excessive and not a recommended feeding schedule for a newborn.

3. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

• A. Administer the prescribed amiodarone (Cordarone) immediately
• B. Institute a daily fluid restriction while the client is in the hospital
• C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
• D. Place the client in the Trendelenburg position to facilitate perfusion

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

4. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Respiratory acidosis

Correct answer: B

Rationale: Pyloric stenosis often leads to metabolic alkalosis due to the loss of gastric acid from vomiting. Metabolic acidosis would not be expected in pyloric stenosis as there is no excessive acid accumulation. Respiratory alkalosis and respiratory acidosis are not typically associated with pyloric stenosis, making them incorrect choices.

5. The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement?

• A. Review the purpose of medications prescribed for the client to take home with him
• B. Provide the client with a printed list of medications and a schedule for administration
• C. Send a list of medications taken while hospitalized to the client’s healthcare provider
• D. Offer to consult with the pharmacist about resources for reduced-price medications

Correct answer: B

Rationale: Providing the client with a printed list of medications and a schedule for administration is crucial to ensure adherence and understanding of the medication regimen at home. This intervention helps the client follow the prescribed treatment plan accurately. Choice A is not as essential since the client already understands when, how, and why to take the medications. Choice C is not a priority at this point as the client needs information for home medication management. Choice D, while helpful, is not the most important intervention compared to providing a clear list and schedule for medication administration.

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