Nursing Elites

1. A nurse is caring for a client with dementia who frequently attempts to get out of bed unsupervised. What is the best intervention?

• A. Use restraints to prevent the client from getting out of bed
• B. Encourage family members to stay with the client at all times
• C. Use a bed exit alarm system
• D. Keep the client's room dark and quiet to reduce stimulation

Correct answer: C

Rationale: The best intervention for a client with dementia who frequently attempts to get out of bed unsupervised is to use a bed exit alarm system (Choice C). A bed exit alarm can alert staff when the client tries to leave the bed, helping to prevent falls. Using restraints (Choice A) is not recommended as it can lead to physical and psychological harm. While having family members present (Choice B) can be beneficial, it may not be feasible at all times. Keeping the client's room dark and quiet (Choice D) may not address the immediate safety concern of the client attempting to get out of bed.

2. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates a hemolytic transfusion reaction?

• A. Chills
• B. Bradycardia
• C. Hypertension
• D. Low back pain

Correct answer: D

Rationale: Low back pain is a classic sign of a hemolytic transfusion reaction and requires immediate intervention. Chills are more commonly associated with a febrile non-hemolytic transfusion reaction. Bradycardia is not a typical sign of a hemolytic transfusion reaction. Hypertension is not a common finding in a hemolytic transfusion reaction.

3. A nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

• A. Urine output of 20 mL/hr.
• B. Temperature of 36.5°C (97.7°F).
• C. Sanguineous drainage on the surgical dressing.
• D. WBC count of 9,000/mm3.

Correct answer: A

Rationale: The correct answer is A: Urine output of 20 mL/hr. A urine output less than 30 mL/hr can indicate decreased renal perfusion, potentially due to hypovolemia or other issues, and should be reported to the provider. B: A temperature of 36.5°C (97.7°F) falls within the normal range and does not require immediate reporting. C: Sanguineous drainage on the surgical dressing is expected in the early postoperative period and should be monitored but does not need immediate reporting unless excessive. D: A WBC count of 9,000/mm3 is within the normal range and does not indicate an immediate concern.

4. A nurse is caring for a client who has been experiencing chronic pain. Which of the following interventions should the nurse implement?

• A. Provide the client with distractions such as television
• B. Administer pain medication around the clock
• C. Teach the client relaxation techniques
• D. Perform massage therapy on the client

Correct answer: C

Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques. This helps the client manage pain more effectively by reducing stress and anxiety, which can contribute to the perception of pain. Providing distractions like television (Choice A) may offer temporary relief but does not address the underlying issue of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote holistic pain management. Massage therapy (Choice D) can be beneficial but may not be as effective as teaching relaxation techniques in the long term for managing chronic pain.

5. A healthcare professional is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the healthcare professional recommend?

• A. Suction the airway every hour
• B. Keep the head of the bed at 30 degrees
• C. Change the ventilator tubing every day
• D. Administer a bronchodilator every 2 hours

Correct answer: B

Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.

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