Nursing Elites

1. When reviewing the medical record of a client with dementia, what should the nurse prioritize addressing?

• A. Mild confusion in the morning
• B. Restlessness and agitation
• C. Incontinence
• D. Frequent wandering at night

Correct answer: B

Rationale: When caring for clients with dementia, addressing restlessness and agitation is a priority as it can lead to distress, safety risks, and potential harm to the client or others. Restlessness and agitation are common behavioral symptoms of dementia and can indicate unmet needs, discomfort, or confusion. Managing these symptoms promptly can help improve the client's quality of life and prevent complications such as falls, injuries, or escalation of challenging behaviors. While other issues like mild confusion, incontinence, and wandering are also important to address, managing restlessness and agitation takes precedence due to its immediate impact on the client's well-being and safety.

2. A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?

• A. Encourage the client to bend at the waist
• B. Maintain the client in a high-Fowler's position
• C. Place a pillow between the client's legs
• D. Avoid placing a pillow under the client's knees

Correct answer: C

Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.

3. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?

• A. The client is anxious about the procedure.
• B. The client has not eaten for 8 hours.
• C. The client has a reported allergy to shellfish.
• D. The client has a platelet count of 100,000/mm³.

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.

4. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

• A. The client is experiencing an adverse reaction to rifampin.
• B. The client's seizure disorder is no longer under control.
• C. The client is showing evidence of phenytoin toxicity.
• D. The client is having adverse effects due to combination antimicrobial therapy.

Correct answer: C

Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.

5. A nurse is caring for a client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

• A. Cross the client's legs at the knees
• B. Maintain the client's legs in a neutral position
• C. Avoid placing a pillow under the client's knees
• D. Elevate the client's legs

Correct answer: C

Rationale: The correct action to prevent dislocation of the prosthesis after hip replacement surgery is to avoid placing a pillow under the client's knees. Placing a pillow can cause hip adduction, leading to dislocation. Crossing the client's legs at the knees and elevating the client's legs can also increase the risk of hip dislocation. Maintaining the client's legs in a neutral position is important to prevent complications.

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