Nursing Elites

1. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

• A. Using a night-light
• B. Demonstrating how to use the call light
• C. Placing the bedside table in close proximity
• D. Hourly rounding by the nurse

Correct answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

2. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

• A. Position the client with the affected extremity lower than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

3. A client is receiving ferrous sulfate. Which of the following should be monitored?

• A. Serum potassium levels
• B. Hemoglobin levels
• C. Liver function tests
• D. Blood glucose levels

Correct answer: B

Rationale: The correct answer is B: Hemoglobin levels. Ferrous sulfate is used to treat iron deficiency anemia by increasing the body's iron stores. Monitoring hemoglobin levels is crucial as it reflects the effectiveness of the treatment in improving the client's anemia. Serum potassium levels (Choice A) are typically not directly affected by ferrous sulfate. Liver function tests (Choice C) and blood glucose levels (Choice D) are not routinely monitored when a client is receiving ferrous sulfate unless there are specific indications or pre-existing conditions that warrant such monitoring.

4. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL per hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?

• A. Increased physical activity
• B. Lowered immune system function
• C. Regular health screenings
• D. Proper nutrition

Correct answer: B

Rationale: The correct answer is B: Lowered immune system function. In older adults, a decline in immune system function increases the risk of developing infections. Increased physical activity (choice A) and proper nutrition (choice D) generally support immune function and overall health, reducing the risk of infections. Regular health screenings (choice C) are important for early detection of health issues but do not directly increase the risk of infections.

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