Nursing Elites

1. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?

• A. Ensure the client is fasting before the test
• B. Provide a warm blanket for the client
• C. Apply cold compresses to the client's chest
• D. Instruct the client to remain still

Correct answer: D

Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.

2. What are the risk factors for developing pneumonia in older adults?

• A. Immobility and decreased lung function
• B. Poor hygiene and aspiration
• C. Use of respiratory equipment and medications
• D. Poor nutritional status and compromised immune system

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

3. A nurse is reviewing the medical record of a client with dementia who frequently becomes agitated. What should the nurse prioritize?

• A. Investigate the client's fluid and electrolyte balance
• B. Investigate the client's recent medication changes
• C. Investigate recent changes in cognitive functioning
• D. Investigate the client's psychosocial environment

Correct answer: B

Rationale: The correct answer is to investigate the client's recent medication changes. In a client with dementia who frequently becomes agitated, medication changes can often be a significant factor contributing to their behavior. Checking recent medication changes can help identify if any specific medication is causing or exacerbating the agitation. Choice A about fluid and electrolyte balance is less likely to be the priority unless there are specific indications in the medical record. Choice C, investigating recent changes in cognitive functioning, may be important but addressing the agitation first is a more immediate concern. Choice D, investigating the client's psychosocial environment, is also important but may not directly address the immediate cause of the agitation as medication changes could.

4. A client post-surgery has a chest tube. What is the most important assessment for the nurse to perform?

• A. Clamp the chest tube for 30 minutes every 4 hours
• B. Check for air leaks and ensure the chest tube is functioning properly
• C. Position the client in a high Fowler's position
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the chest tube is functioning properly. This is crucial post-surgery to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube, positioning the client, or encouraging coughing are not appropriate assessments for a client with a chest tube post-surgery and could lead to serious issues if done incorrectly.

5. Which of the following interventions should the nurse prioritize for a client with dementia who is at risk of falls?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm system to notify staff when the client attempts to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct answer is B. Using a bed exit alarm system is a non-restrictive intervention that alerts staff when the client tries to leave the bed, promoting safety and preventing falls. Choice A is incorrect because using restraints can have adverse effects and should be avoided whenever possible. Choice C is not the priority for a client at risk of falls due to dementia as it may increase the risk of falls without proper supervision. Choice D is also not recommended as raising all four side rails can lead to restraint and should be used cautiously, if at all. Therefore, the best option is to use a bed exit alarm system to ensure the client's safety while allowing some freedom of movement.

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