Nursing Elites

1. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

• A. Lock beds and wheelchairs when not in use
• B. Administer a sedative at bedtime
• C. Provide information about home safety checks
• D. Teach balance and strengthening exercises

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

2. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?

• A. Encourage physical activity to reduce withdrawal symptoms
• B. Administer diazepam to prevent seizures
• C. Monitor for signs of dehydration
• D. Encourage the client to verbalize their feelings

Correct answer: B

Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.

3. A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?

• A. An abnormal stance
• B. Injury to the nerves
• C. A fall and further injury
• D. Skin breakdown

Correct answer: B

Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.

4. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?

• A. White blood cell count (WBC)
• B. C-reactive protein (CRP)
• C. Erythrocyte sedimentation rate (ESR)
• D. Hemoglobin and hematocrit levels

Correct answer: A

Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.

5. Which nursing action will best help a patient with diabetes manage their condition?

• A. Monitor the patient's blood sugar levels regularly.
• B. Encourage the patient to follow a diabetic meal plan.
• C. Teach the patient how to administer insulin.
• D. Teach the patient about the complications of diabetes.

Correct answer: C

Rationale: The correct answer is C: Teach the patient how to administer insulin. This action is crucial in promoting self-management and control of diabetes. By educating the patient on administering insulin, they can actively participate in their treatment plan. Monitoring blood sugar levels (choice A) is important but doesn't empower the patient to take direct action. Encouraging a diabetic meal plan (choice B) is beneficial but may not directly address the need for insulin administration. Teaching about the complications of diabetes (choice D) is essential but may not be as immediately impactful as teaching insulin administration for day-to-day management.

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