Nursing Elites

1. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

2. A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?

• A. Eat high-protein foods.
• B. Lie down after meals.
• C. Drink water with meals.
• D. Eat dry carbohydrates before getting out of bed.

Correct answer: D

Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.

3. A client has a central venous catheter. Which of the following actions should be taken to prevent an air embolism?

• A. Keep the catheter clamped when not in use
• B. Have the client perform the Valsalva maneuver while the catheter is removed
• C. Use a non-coring needle to access the catheter
• D. Flush the catheter with 0.9% sodium chloride every 24 hours

Correct answer: B

Rationale: The correct action to prevent an air embolism in a client with a central venous catheter is to have the client perform the Valsalva maneuver while the catheter is removed. This maneuver helps to close the airway and prevent air from entering the bloodstream. Keeping the catheter clamped at all times (Choice A) is not necessary and may lead to clot formation. Using a non-coring needle (Choice C) is important for accessing the catheter but does not specifically prevent air embolism. Flushing the catheter with 0.9% sodium chloride (Choice D) helps maintain patency but does not directly prevent air embolism.

4. A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?

• A. Withhold the next dose
• B. Increase the dosage
• C. Discontinue the medication
• D. Administer the medication

Correct answer: D

Rationale: The correct answer is to administer the medication (Choice D) since the lithium level of 0.8 mEq/L falls within the therapeutic range of 0.6-1.2 mEq/L. Withholding the next dose (Choice A) or increasing the dosage (Choice B) is not necessary as the current level is appropriate. Discontinuing the medication (Choice C) is not warranted based on the given lithium level. It is crucial to maintain therapeutic levels to ensure the medication's effectiveness without causing toxicity.

5. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

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