Nursing Elites

1. What intervention should be taken to minimize the risk for injury in a client with dementia?

• A. Use a bed exit alarm system.
• B. Place the client in restraints for safety.
• C. Ensure the client has frequent visitors to reduce isolation.
• D. Keep the client's room dark and quiet at night.

Correct answer: A

Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.

2. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

• A. We need to document the exact medication you were taking because you might be allergic to it.
• B. You should take a different type of antibiotic this time.
• C. A rash is a common reaction and is not usually concerning.
• D. You can take the same antibiotic again if needed.

Correct answer: A

Rationale: The nurse should advise the client to document the exact medication taken to identify potential allergies and prevent adverse reactions. This is important as the client developed a rash previously while taking an antibiotic, indicating a possible allergic reaction. Choice B is not appropriate as switching antibiotics without proper evaluation can be risky. Choice C is incorrect as rashes should not be dismissed without further investigation, especially in the context of taking medication. Choice D is also not recommended as re-taking the same antibiotic without clarifying the allergic reaction can lead to a potentially severe outcome.

3. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?

• A. Complete a fall-risk assessment.
• B. Educate the client and family about fall risks.
• C. Eliminate safety hazards from the client’s environment.
• D. Ensure the client uses assistive aids in their possession.

Correct answer: C

Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.

4. A healthcare provider is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the healthcare provider take?

• A. Insert the IV catheter without using a tourniquet.
• B. Use the tourniquet minimally or not at all to avoid injury to fragile skin or veins.
• C. Insert the IV catheter at a 45-degree angle.
• D. Use a smaller gauge catheter to reduce vein trauma.

Correct answer: B

Rationale: When initiating IV therapy in older adults, it is essential to use the tourniquet minimally or not at all to prevent potential injury to fragile skin or veins. The use of a tourniquet can lead to increased venous pressure and potentially cause vein damage in older adult clients. Choice A is incorrect because inserting the IV catheter without a tourniquet can make locating veins more challenging. Choice C is incorrect as inserting the IV catheter at a 45-degree angle is not a recommended practice and can increase the risk of complications. Choice D is incorrect because using a smaller gauge catheter may not be appropriate for older adults who may require a larger gauge catheter for adequate fluid administration.

5. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?

• A. Dyspnea
• B. Heart murmur
• C. Macular rash
• D. Hemorrhage

Correct answer: B

Rationale: A new or changed heart murmur is a common sign of valve involvement in infective endocarditis, indicating a complication such as valve damage or regurgitation. Dyspnea is more commonly associated with respiratory or cardiac conditions not directly related to infective endocarditis. A macular rash is not a typical symptom of infective endocarditis, suggesting other conditions like infectious diseases. Hemorrhage is not a direct complication of infective endocarditis but may occur due to factors such as anticoagulant therapy or underlying bleeding disorders.

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