Nursing Elites

1. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

• A. Loud volume of the television set
• B. Wall-to-wall carpet in the living room
• C. Low chairs without armrests
• D. Use of indirect lighting

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

2. A healthcare provider is reviewing the medical record of a client who has a new prescription for clozapine. Which of the following findings indicates a contraindication to clozapine?

• A. Fasting blood glucose of 120 mg/dL
• B. Asthma
• C. Hypertension
• D. WBC count of 3,300/mm3

Correct answer: D

Rationale: A low WBC count (3,300/mm3) is a contraindication to clozapine because this medication can cause severe neutropenia. Neutropenia is a significant reduction in white blood cell count, increasing the risk of infections. Elevated fasting blood glucose, asthma, and hypertension are not direct contraindications to clozapine.

3. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?

• A. Confront the nurse about the behavior.
• B. Notify the hospital's safety committee.
• C. Document the observation without addressing it.
• D. Follow up with the nurse at a later time.

Correct answer: B

Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.

4. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?

• A. Redness and swelling are normal after surgery
• B. Any drainage from the incision site is not concerning
• C. Yellow drainage is normal
• D. I should monitor for increased redness or warmth

Correct answer: B

Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.

5. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

• A. Suggest that the client use a salt substitute
• B. Obtain a 12-lead ECG
• C. Obtain a blood sample for a serum sodium level
• D. Advise the client to add citrus juices and bananas to their diet

Correct answer: B

Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.

Similar Questions