Nursing Elites

1. The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?

• A. Remove the glass of water and speak to the UAP.
• B. Discuss the incident with the UAP at the end of the day.
• C. Write an incident report and notify the healthcare provider.
• D. Remind the client of the potential for electrolyte imbalance.

Correct answer: A

Rationale: The correct action for the charge nurse to take is to remove the glass of water and speak to the UAP. This ensures immediate correction and education to prevent further issues with the nasogastric tube. Addressing the situation promptly can prevent harm to the client and reinforces the importance of following proper protocols.

2. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?

• A. Encourage the client to remove the gun from her possession.
• B. Notify the client's healthcare provider of the availability of the weapon.
• C. Contact a person of the client's choosing to remove the weapon from the home.
• D. Call the local police department and have the weapon removed from the home.

Correct answer: C

Rationale: In this scenario, it is crucial to maintain the client's confidentiality while ensuring her safety. Contacting a person chosen by the client to remove the weapon from her home is the best course of action. This approach respects the client's autonomy and helps reduce the risk of harm without involving external authorities unnecessarily.

3. The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?

• A. Discontinue the IV and apply pressure at the site.
• B. Decrease the saline to a keep-open rate.
• C. Increase the rate of the current IV solution.
• D. Change the IV fluid to 0.45% normal saline at the same rate.

Correct answer: B

Rationale: In this scenario, the client is showing signs of fluid overload with tachypnea and a high pulse rate. Decreasing the saline to a keep-open rate is appropriate to prevent further fluid volume excess. This action allows for IV access to be maintained while reducing the fluid administered, helping to manage the symptoms of fluid overload.

4. A client with a history of chronic alcohol use is admitted with confusion and an unsteady gait. Which deficiency should the nurse suspect?

• A. Thiamine (Vitamin B1)
• B. Cyanocobalamin (Vitamin B12)
• C. Folic acid
• D. Vitamin D

Correct answer: A

Rationale: The correct answer is Thiamine (Vitamin B1). Chronic alcohol use can lead to thiamine deficiency, which can result in neurological symptoms such as confusion and an unsteady gait. Thiamine is essential for proper brain function and nerve conduction, and its deficiency is common in individuals with alcohol use disorder. Cyanocobalamin (Vitamin B12) deficiency can also present with neurological symptoms, but in this case, the patient's history of chronic alcohol use points more towards thiamine deficiency. Folic acid deficiency typically presents with symptoms like fatigue and megaloblastic anemia. Vitamin D deficiency is associated with bone health issues rather than neurological symptoms.

5. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?

• A. Apply a moisturizing cream to the affected areas.
• B. Encourage the client to consume foods rich in vitamin B.
• C. Notify the healthcare provider for further evaluation.
• D. Ensure that the client gets adequate B vitamins in foods or supplements.

Correct answer: D

Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.

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