Nursing Elites

1. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

2. A healthcare professional is teaching a group of assistive personnel about the expected integumentary changes in older adults. Which change should the healthcare professional include?

• A. Increase in skin turgor
• B. Increase in subcutaneous fat
• C. Decrease in moisture levels
• D. Increase in oil production

Correct answer: C

Rationale: The correct answer is C: Decrease in moisture levels. In older adults, there is a reduction in oil production, leading to decreased moisture levels in the skin. This change can result in dry skin and increased risk of skin issues. The other choices are incorrect because in older adults, skin turgor tends to decrease, subcutaneous fat may decrease, and oil production typically decreases rather than increases.

3. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?

• A. Apply a cold compress
• B. Discontinue the IV line
• C. Elevate the limb
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.

4. A client is being taught about measures to promote sleep for insomnia. Which client statement indicates understanding?

• A. I will take naps during the day to help me sleep at night
• B. I should drink caffeine to help me stay awake during the day
• C. I should reduce my fluid intake 2 hours before bedtime
• D. I should exercise right before bed to tire myself out

Correct answer: C

Rationale: The correct answer is C. By reducing fluid intake 2 hours before bedtime, the client can prevent nighttime awakenings to urinate, which promotes better sleep. Napping during the day (choice A) may interfere with nighttime sleep. Drinking caffeine (choice B) can disrupt sleep patterns. Exercising right before bed (choice D) can actually stimulate the body and make it harder to fall asleep.

5. A nurse is caring for a client who is receiving continuous enteral feedings. What finding indicates intolerance to the feeding?

• A. Weight gain
• B. Nausea
• C. Constipation
• D. Elevated heart rate

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain is not typically associated with intolerance to enteral feedings; instead, it may indicate other issues such as fluid retention. Constipation is also not a direct indicator of intolerance to enteral feedings. While an elevated heart rate can occur for various reasons, it is less specific to enteral feeding intolerance compared to nausea.

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