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. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

• A. Bilateral Wheezing
• B. Urticaria
• C. Peripheral edema
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Urticaria. An itchy rash following a change in detergent may indicate an allergic reaction, specifically urticaria (hives), which requires immediate attention. Urticaria can be a sign of a severe allergic reaction, such as anaphylaxis. Bilateral wheezing (choice A) may suggest respiratory issues like asthma but is not directly related to the skin rash. Peripheral edema (choice C) and elevated blood pressure (choice D) are not typically associated with an allergic reaction to laundry detergent and would not be the priority assessment findings in this scenario.

3. Following a thyroidectomy, a client experiences tetany. The nurse should expect to administer which intravenous medication?

• A. Sodium iodide solution
• B. Levothyroxine sodium (Synthroid)
• C. Calcium gluconate
• D. Propranolol (Inderal)

Correct answer: C

Rationale: Following a thyroidectomy, tetany can occur due to hypoparathyroidism, leading to low calcium levels. Therefore, the nurse should administer calcium gluconate intravenously to raise the calcium levels. Choice A, Sodium iodide solution, is incorrect as it is used for thyroid conditions, not for treating tetany. Choice B, Levothyroxine sodium (Synthroid), is incorrect as it is a thyroid hormone replacement and does not address low calcium levels. Choice D, Propranolol (Inderal), is incorrect as it is a beta-blocker used for conditions like hypertension and not indicated for tetany after thyroidectomy.

4. An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client’s spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?

• A. Reassure the spouse that the client will be well cared for and provide information about the facility’s care practices.
• B. Inform the spouse that care will be adjusted based on the client’s condition and needs.
• C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
• D. Suggest that the spouse speak with other family members for reassurance.

Correct answer: A

Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility’s care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.

5. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

• A. An older client receiving packed RBCs on the third day postoperatively for colon resection
• B. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery
• C. An adult one day postoperatively from laparoscopic cholecystectomy requesting pain medication
• D. An adult in Buck’s traction, scheduled for hip arthroplasty within the next 12 hours

Correct answer: B

Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.

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