Nursing Elites

1. A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?

• A. Keep the client's bed in the lowest position.
• B. Encourage the client to wear non-slip socks.
• C. Place a fall risk sign on the client's door.
• D. Use a gait belt when ambulating the client.

Correct answer: A

Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.

2. A nurse is caring for an older, immobile patient whose condition requires a supine position. Which metabolic alteration will the nurse monitor for in this patient?

• A. Increased appetite
• B. Increased diarrhea
• C. Increased metabolic rate
• D. Increased pulse rate

Correct answer: D

Rationale: When an older, immobile patient is in a supine position, it increases cardiac workload, leading to an increased pulse rate. This is because the heart rate in older adults may not tolerate the additional workload. Choices A, B, and C are incorrect because an increased appetite, increased diarrhea, and increased metabolic rate are not directly associated with being immobile in a supine position. Increased appetite is more related to nutritional needs or certain medical conditions, increased diarrhea could be due to various causes, and an increased metabolic rate is not typically a direct consequence of lying supine.

3. A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

• A. “This test will indicate if you are at risk for developing blood clots.”
• B. “This test will determine if your heart is performing properly.”
• C. “This test will provide information about the function of your liver.”
• D. “This test is used to check how your kidneys are working.”

Correct answer: C

Rationale: The correct answer is C: “This test will provide information about the function of your liver.” Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.

4. The healthcare provider retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the healthcare provider administer to the client?

• A. 0.75 mL
• B. 1 mL
• C. 0.8 mL
• D. 1.2 mL

Correct answer: C

Rationale: The correct dosage calculation is to divide the prescribed dose by the concentration of the medication to determine the volume needed. In this case, 3 mg (prescribed dose) divided by 4 mg/mL (concentration) equals 0.75 mL. Therefore, the healthcare provider should administer 0.75 mL of hydromorphone to the client. Choices A, B, and D are incorrect because they do not accurately calculate the required volume based on the prescription and concentration provided.

5. A client who had a stroke requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult?

• A. Registered dietitian.
• B. Occupational therapist.
• C. Speech-language pathologist.
• D. Physical therapist.

Correct answer: B

Rationale: The correct answer is B, Occupational therapist. An occupational therapist specializes in assisting clients with daily living activities, making them crucial for a stroke patient requiring help with morning activities of daily living (ADLs). While a registered dietitian (A) may provide nutritional guidance, a speech-language pathologist (C) focuses on communication and swallowing disorders, and a physical therapist (D) primarily deals with mobility and physical rehabilitation. However, none of these professionals directly address the specific needs related to ADLs following a stroke as effectively as an occupational therapist.

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