Nursing Elites

1. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

2. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials?

• A. Solid foods are introduced one at a time beginning with cereal.
• B. Finely ground meat should be avoided early to provide iron.
• C. Egg white is not recommended early to increase protein intake.
• D. Solid foods should not be mixed with formula in a bottle.

Correct answer: A

Rationale: The correct answer is A. Introducing solid foods one at a time, starting with cereal, is recommended to monitor for any food allergies or intolerances in infants. Choice B is incorrect as finely ground meat should be introduced later due to the risk of choking and is not necessary for iron intake. Choice C is incorrect as egg white should be avoided early due to the risk of allergies. Choice D is incorrect as solid foods should not be mixed with formula in a bottle to prevent overfeeding and promote healthy eating habits.

3. In a client with liver cirrhosis, which symptom would be most concerning during assessment?

• A. Jaundice
• B. Ascites
• C. Hepatomegaly
• D. Altered mental status

Correct answer: D

Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.

4. A nurse is planning care for a client who had a stroke. What task should be assigned to the assistive personnel?

• A. Assist the client with a partial bed bath
• B. Measure the client’s blood pressure after the nurse administers antihypertensive medications
• C. Use a communication board to ask what the client wants for lunch
• D. Feed the client

Correct answer: A

Rationale: The correct answer is to assign the assistive personnel to assist the client with a partial bed bath. This task falls within the scope of practice for assistive personnel and is a common activity in caring for clients who have had a stroke. Choice B involves measuring blood pressure, which should be done by a licensed nurse. Choice C requires the use of a communication board, which can be done by any healthcare team member, not just assistive personnel. Choice D involves feeding the client, which may require assessment and intervention by a licensed nurse to ensure proper nutrition and safety.

5. During a blood transfusion, which observation indicates that the client is experiencing a transfusion reaction?

• A. The client reports feeling warm and flushed.
• B. The client develops a rash on the chest and back.
• C. The client experiences chills and a fever.
• D. The client complains of back pain and shortness of breath.

Correct answer: D

Rationale: Complaints of back pain and shortness of breath are classic signs of a transfusion reaction, specifically indicating a hemolytic reaction. This reaction can lead to the release of hemoglobin into the bloodstream, causing back pain and shortness of breath due to clot formation in the blood vessels, leading to decreased oxygen delivery. Warmth, flushing, rash, chills, and fever are more commonly associated with allergic reactions or febrile non-hemolytic reactions during transfusions. Therefore, options A, B, and C are incorrect in this context.

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