Nursing Elites

1. A nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.

2. A client with type 1 DM is being taught about hypoglycemia by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “Exercise decreases the risk of hypoglycemia.”
• B. “I should skip my insulin if I don't eat.”
• C. “I can drink 4 oz of regular soda if my blood sugar is low.”
• D. “Oral diabetic medications do not lead to hypoglycemia; only insulin does.”

Correct answer: C

Rationale: The correct answer is C because the client should have a quick-acting source of 15 g of carbohydrates to treat hypoglycemic episodes, such as 4 oz of regular soda. Choice A is incorrect because while exercise can help manage blood sugar levels, it can also increase the risk of hypoglycemia if not properly managed. Choice B is incorrect as skipping insulin when not eating can lead to hyperglycemia, not prevent hypoglycemia. Choice D is incorrect because certain oral diabetic medications can indeed cause hypoglycemia, not just insulin.

3. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?

• A. A client who reports tingling in the fingers following a thyroidectomy
• B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
• C. A client who is in a long leg cast and reports cool feet bilaterally
• D. A client who has a productive cough and an oral temperature of 36°C (96.8°F)

Correct answer: C

Rationale: The correct answer is C. Cool feet bilaterally in a client with a long leg cast may indicate compromised circulation, which is a medical emergency that requires immediate intervention. Choices A, B, and D do not present immediate life-threatening conditions. Tingling in the fingers following a thyroidectomy may indicate hypocalcemia but does not require immediate attention. Dark, foul-smelling urine with decreased urine output indicates a possible urinary tract infection or dehydration but can be addressed after attending to the client with compromised circulation. A productive cough and a normal oral temperature do not suggest an urgent condition compared to compromised circulation in a client with a long leg cast.

4. A nurse is planning care for a patient who follows the Mormon belief system. What modifications should the nurse include to meet Mormon dietary practices?

• A. Offer only vegetarian meal options.
• B. Offer non-caffeinated beverage options.
• C. Offer kosher meals.
• D. Limit meat to only fish and poultry.

Correct answer: B

Rationale: The correct answer is B: Offer non-caffeinated beverage options. Mormons avoid caffeinated beverages, so providing non-caffeinated options aligns with their religious practices. Choice A is incorrect because offering only vegetarian meal options is not a specific requirement of the Mormon dietary practices. Choice C is incorrect as kosher meals are associated with Jewish dietary laws, not specific to the Mormon belief system. Choice D is incorrect as limiting meat to only fish and poultry is not a specific dietary requirement for Mormons.

5. A client with severe preeclampsia is receiving magnesium sulfate intravenously. Which action should the nurse take when toxicity occurs?

• A. Position the client supine
• B. Prepare an IV bolus of dextrose 5%
• C. Administer calcium gluconate IV
• D. Administer methylergonovine IM

Correct answer: C

Rationale: When toxicity from magnesium sulfate occurs, the nurse should administer calcium gluconate IV as it is the antidote for magnesium sulfate toxicity. Positioning the client supine may not address the toxicity issue. Administering dextrose 5% is not the appropriate intervention for magnesium sulfate toxicity. Methylergonovine is used to manage postpartum hemorrhage and is not indicated for magnesium sulfate toxicity.

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