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. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will mix the medication with applesauce
• B. I will provide a snack with the medication
• C. I will store the medication in the refrigerator
• D. I will swab the inside of my child's mouth with the medication

Correct answer: D

Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.

3. Which finding in a postoperative patient requires immediate intervention by the nurse?

• A. Heart rate of 88 beats per minute.
• B. Blood pressure of 130/80 mmHg.
• C. Crackles heard in the lung bases.
• D. Oxygen saturation of 88% on room air.

Correct answer: D

Rationale: In a postoperative patient, an oxygen saturation level of 88% on room air indicates a significant drop below the normal range, suggesting potential respiratory distress. This finding requires immediate intervention by the nurse to ensure the patient receives adequate oxygenation. A heart rate of 88 beats per minute is within the normal range, making it a less concerning finding. A blood pressure of 130/80 mmHg falls within the normal range for blood pressure and does not require immediate intervention. Crackles heard in the lung bases may indicate fluid accumulation but may not always require immediate intervention unless accompanied by other concerning signs or symptoms.

4. A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer?

• A. 1
• B. 2
• C. 3
• D. 4

Correct answer: B

Rationale: The correct answer is B: 2. To achieve the prescribed dose of 0.25 mg of digoxin, the nurse should administer two 0.125 mg tablets. This calculation ensures that the patient receives the correct amount of medication. Choices A, C, and D are incorrect because they do not reflect the accurate dosage needed based on the available tablets and prescribed dose.

5. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

• A. To donate organs, a client must provide consent prior to death
• B. The transplant team will harvest the organs for donation from the donor client
• C. During admission, all clients over the age of 18 should be asked about their organ donor status
• D. The National Organ Transplant Act prohibits the sale and purchase of organs

Correct answer: C

Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.

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