Nursing Elites

1. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

• A. Educate the client about their current medical diagnosis.
• B. Refer the client to a meal delivery program.
• C. Identify environmental hazards in the home.
• D. Arrange transportation for the client to follow-up appointments.

Correct answer: C

Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.

2. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?

• A. Allow the client to sleep undisturbed
• B. Administer oxygen via facemask or nasal prongs
• C. Administer naloxone (Narcan)
• D. Place epinephrine 1:1,000 at the bedside

Correct answer: C

Rationale: The correct answer is to administer naloxone (Narcan). The client's vital signs indicate opioid-induced respiratory depression, which is a potential side effect of morphine. Naloxone is used to reverse the effects of opioids, particularly to restore normal respiratory function. Administering oxygen alone (Choice B) may not address the underlying cause of respiratory depression. Allowing the client to sleep undisturbed (Choice A) is inappropriate when signs of respiratory depression are present. Epinephrine (Choice D) is not indicated in this situation and is not used to reverse opioid effects.

3. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

4. A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

• A. Keep the client awake
• B. Instruct the client not to get out of bed
• C. Encourage the client to drink fluids
• D. Encourage early ambulation

Correct answer: B

Rationale: The correct answer is to instruct the client not to get out of bed. Lorazepam is a sedative that can cause drowsiness and impair coordination. By instructing the client not to get out of bed, the nurse helps prevent falls or injuries that could occur due to the medication's sedative effects. Choice A is incorrect as keeping the client awake may not be necessary and could lead to unnecessary discomfort. Choice C is incorrect as encouraging the client to drink fluids is not directly related to the administration of lorazepam. Choice D is incorrect as early ambulation is not safe immediately after administering a sedative medication.

5. A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?

• A. The client's urination habits.
• B. The client's financial information.
• C. The client's social history.
• D. The client's current level of mobility.

Correct answer: D

Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.

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