Nursing Elites

1. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused.
• B. Request a prescription for PRN restraints when the client is wandering.
• C. Dim the lighting in the client's room.
• D. Leave one side rail up on the client's bed.

Correct answer: C

Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.

2. A client at 10 weeks of gestation with a history of UTIs is receiving teaching from a nurse. Which of the following statements should the nurse include?

• A. You should drink 240 ml (8 oz) of water before and after intercourse.
• B. You should avoid drinking orange juice because it increases the risk of infection.
• C. You should empty your bladder after intercourse to help prevent infection.
• D. You should take a hot bath to help prevent infection.

Correct answer: C

Rationale: The correct statement the nurse should include is to advise the client to empty their bladder after intercourse to help prevent UTIs. Emptying the bladder after intercourse helps reduce the risk of UTIs by flushing bacteria from the urethra. Choice A is incorrect as drinking water before and after intercourse is not specifically related to preventing UTIs. Choice B is incorrect as there is no direct correlation between orange juice consumption and UTI risk. Choice D is incorrect as taking a hot bath can actually increase the risk of UTIs by promoting bacterial growth.

3. A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following actions should the nurse take?

• A. Give the medication as a bolus over 10 minutes.
• B. Dilute the medication before administration.
• C. Infuse the medication at a rate of 10 mEq/hr.
• D. Administer the medication undiluted.

Correct answer: C

Rationale: The correct action the nurse should take when administering potassium chloride IV to a client with hypokalemia is to infuse the medication at a rate of 10 mEq/hr. This slow infusion rate is crucial to prevent the development of hyperkalemia, a potentially dangerous condition. Option A is incorrect because giving the medication as a bolus over 10 minutes can lead to adverse effects. Option B is incorrect as potassium chloride does not necessarily need to be diluted before administration in this scenario. Option D is incorrect as administering the medication undiluted can also increase the risk of hyperkalemia.

4. How should fluid balance be assessed in a patient with heart failure?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

5. A nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?

• A. Inject the medication into the deltoid muscle
• B. Inject the medication deep into subcutaneous tissue
• C. Massage the injection site for 2 minutes after administration
• D. Insert the needle at a 10-degree angle

Correct answer: B

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication deep into subcutaneous tissue. This method helps ensure proper absorption of the medication and prevents tissue irritation. Injecting into the deltoid muscle (Choice A) is not recommended for enoxaparin administration. Massaging the injection site (Choice C) can lead to tissue damage and bruising. Inserting the needle at a 10-degree angle (Choice D) is not the correct technique for administering enoxaparin.

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