Nursing Elites

1. A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client’s continuity of care?

• A. Plan to assign the client a different nurse each shift
• B. Limit the number of interdisciplinary team members involved in managing the client’s care
• C. Request that the client complete a satisfaction survey at discharge
• D. Start discharge planning on the day of admission

Correct answer: D

Rationale: Starting discharge planning on the day of admission is crucial to ensuring a smooth transition and continuity of care for the client. It allows for early identification of needs, coordination of services, and timely interventions. Assigning a different nurse each shift (Choice A) can disrupt continuity of care and lead to inconsistencies in the client's treatment. Limiting the number of interdisciplinary team members (Choice B) may hinder comprehensive care coordination. Requesting a satisfaction survey at discharge (Choice C) focuses more on feedback rather than proactive care planning and coordination.

2. When teaching a client how to administer medication through a jejunostomy tube, which of the following instructions should the nurse include?

• A. Flush the tube before and after each medication.
• B. Mix medications with enteral feeding.
• C. Push tablets through the tube slowly.
• D. Mix crushed medications before dissolving them in water.

Correct answer: A

Rationale: The correct answer is to flush the tube before and after each medication administration. This helps prevent clogging and ensures the medication is delivered properly. Mixing medications with enteral feeding (choice B) is incorrect as medications should be administered separately. Pushing tablets through the tube (choice C) is not recommended as they should be properly dissolved before administration. Mixing all crushed medications before dissolving them in water (choice D) is incorrect; medications should be dissolved individually to avoid interactions or inconsistencies in dosages.

3. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

• A. Dry mucous membranes
• B. Increased urine output
• C. Decreased heart rate
• D. Elevated blood pressure

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

4. A client is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

• A. Hemolytic
• B. Allergic
• C. Febrile
• D. Transfusion-related acute lung injury (TRALI)

Correct answer: A

Rationale: The correct answer is A: Hemolytic. Hemolytic reactions can lead to flank pain and hemoglobinuria, as the body breaks down the transfused red blood cells. In hemolytic reactions, the immune system attacks and destroys the transfused red blood cells, causing the release of hemoglobin into the bloodstream and urine. This results in reddish-brown urine, indicating hemoglobinuria. Allergic reactions typically present with symptoms like itching, hives, or rash. Febrile reactions are characterized by fever, chills, and rigors. TRALI is a rare but serious transfusion reaction that manifests as acute respiratory distress following a transfusion, not flank pain and hemoglobinuria.

5. When developing a plan of care for a client with dementia, what should the LPN/LVN remember about confusion in the elderly?

• A. It is not a normal part of aging.
• B. It often follows relocation to new surroundings.
• C. It is primarily due to changes in the brain associated with the disease.
• D. It cannot be prevented or cured by adequate sleep alone.

Correct answer: B

Rationale: When caring for a client with dementia, it is crucial to understand that confusion often arises after relocating to new surroundings. This change can disrupt familiar routines and trigger increased disorientation and confusion. Choice A is correct because confusion in the elderly is not a normal part of aging. Choice C is incorrect because confusion in dementia is primarily due to changes in the brain associated with the disease, not just irreversible brain pathology. Choice D is incorrect because while adequate sleep is important for overall health, it alone cannot prevent or cure confusion associated with dementia.

Similar Questions