Nursing Elites

1. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

2. What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?

• A. Take the medication with food
• B. Avoid foods high in tyramine
• C. Report any thoughts of self-harm immediately
• D. Expect to see improvement within 24 hours

Correct answer: C

Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.

3. Which client assessment falls within the scope of practice for the practical nurse?

• A. An agitated client with bilateral wrist restraints
• B. New admission of a client with deep vein thrombosis
• C. Return of a post-anesthesia client following a colon resection
• D. Transfer of a client with sepsis from a long-term care facility

Correct answer: B

Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.

4. Which client is at the highest risk for developing pressure ulcers?

• A. A 50-year-old client with a fractured femur
• B. A 30-year-old client with diabetes mellitus
• C. A 65-year-old client with limited mobility
• D. A 70-year-old client with a history of stroke

Correct answer: C

Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.

5. What is the most important action to prevent complications while caring for a client receiving enteral nutrition via a nasogastric tube?

• A. Check tube placement before each feeding
• B. Flush the tube with water before and after each feeding
• C. Elevate the head of the bed to 30 degrees
• D. Administer the feeding at room temperature

Correct answer: A

Rationale: Checking tube placement before each feeding is crucial to prevent aspiration, a serious complication of enteral nutrition. Ensuring the tube is correctly positioned in the stomach helps avoid the risk of the feeding going into the lungs, which can lead to aspiration pneumonia. Flushing the tube with water (Choice B) is important for maintaining tube patency but is not the most critical action to prevent complications. Elevating the head of the bed (Choice C) helps reduce the risk of aspiration but is not as crucial as verifying tube placement. Administering the feeding at room temperature (Choice D) is more related to patient comfort and does not directly address the prevention of complications associated with enteral nutrition via a nasogastric tube.

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