Nursing Elites

1. A client with vision loss is being cared for by a nurse. Which of the following actions should the nurse take?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Touch the client gently to announce presence

Correct answer: A

Rationale: The correct action for the nurse to take is to keep objects in the client's room in the same place. This helps individuals with vision loss navigate their environment more easily by creating a familiar and consistent layout. Choice B, ensuring high-wattage lighting, may not be suitable for all clients with vision loss and can cause discomfort or glare. Approaching the client from the side (Choice C) can startle them and is not recommended. Touching the client (Choice D) without warning may cause anxiety or distress, so it's important to announce presence verbally.

2. How should a healthcare professional care for a patient with a central line?

• A. Flush the line daily
• B. Monitor for infection
• C. Change the dressing weekly
• D. Replace the central line every week

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is crucial. This is because central lines can introduce bacteria into the bloodstream, leading to serious infections. While flushing the line daily and changing the dressing weekly are important aspects of central line care, monitoring for infection takes precedence. Infections can occur rapidly and have severe consequences, so early detection through vigilant monitoring is key. Replacing the central line every week is not a standard practice and should only be done when clinically indicated, such as in cases of infection or malfunction.

3. A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

• A. WBC 4,500/mm3
• B. Hemoglobin 12 g/dL
• C. Platelet count 250,000/mm3
• D. Platelet count 100,000/mm3

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm3 is lower than the normal range, indicating thrombocytopenia, which is concerning in clients receiving chemotherapy. Thrombocytopenia can lead to an increased risk of bleeding and bruising. Choices A, B, and C fall within the normal range and would not be a cause for concern in a client receiving chemotherapy.

4. A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?

• A. Heart rate 58/min.
• B. Fasting blood glucose 100 mg/dL.
• C. Hgb 14 g/dL.
• D. WBC count 2,900/mm3.

Correct answer: D

Rationale: The correct answer is D: a low WBC count. Clozapine can suppress bone marrow function, leading to a decreased white blood cell count. This condition, known as agranulocytosis, increases the risk of severe infections. Monitoring WBC counts is essential during clozapine therapy. Choices A, B, and C are within normal ranges and are not contraindications for administering clozapine.

5. What is the best intervention for a patient with dehydration?

• A. Administer IV fluids
• B. Provide oral fluids
• C. Encourage fluid intake
• D. Administer electrolytes

Correct answer: A

Rationale: Administering IV fluids is the best intervention for a patient with dehydration because it is the fastest and most effective way to rehydrate the body. IV fluids can quickly restore fluid volume and electrolyte balance in severe cases of dehydration. Providing oral fluids or encouraging fluid intake may not be sufficient for patients with moderate to severe dehydration, as they may have impaired gastrointestinal absorption. While electrolytes are essential for rehydration, administering them alone without fluid replacement may not address the primary issue of fluid loss in dehydration.

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