Nursing Elites

1. The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?

• A. A 69-year-old widowed female who lives alone and volunteers at a school
• B. A 95-year-old ambulatory male who resides in a nursing home in a small town
• C. A 78-year-old female on a fixed income who lives with her relatives
• D. An 81-year-old male with diabetes who lives with his wife of 52 years

Correct answer: C

Rationale: Elder abuse risk is higher in individuals who live with relatives and are on a fixed income as these factors can contribute to vulnerability. Living with relatives may expose the individual to potential abusive situations within the family dynamics. Additionally, being on a fixed income may limit financial independence and increase dependency on others, potentially leading to financial abuse. The other options, such as living alone and volunteering, residing in a nursing home, or living with a long-term spouse, do not inherently pose the same level of risk factors for elder abuse as living with relatives on a fixed income.

2. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

• A. Ask the client about soft food preferences
• B. Auscultate the client’s breath sounds
• C. Obtain and record the client’s vital signs
• D. Determine which side of the body is weak

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

3. A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hour?

• A. 18
• B. 27
• C. 36
• D. 45

Correct answer: D

Rationale: The infusion rate is calculated based on the concentration of lidocaine and the prescribed rate of infusion. First, convert lidocaine's weight to milligrams (2 grams = 2000 mg). Then, use the formula: (Total volume in ml * dose in mg) / 60 minutes. For this case, (500 ml * 2000 mg) / 60 minutes = 45 ml/hour. Therefore, the correct answer is D. Choices A, B, and C are incorrect as they do not reflect the accurate calculation based on the provided concentration and infusion rate.

4. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

• A. Increase wall suction while removing the suction catheter
• B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
• C. Suction the client’s oropharynx after tracheal suctioning
• D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

5. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

• A. Weigh at the same time every day
• B. Report weight gain of 2 pounds (0.9kg) in 24 hours
• C. Maintain a daily weight record
• D. Limit dietary salt intake

Correct answer: B

Rationale: The correct answer is B. Reporting a weight gain of 2 pounds in 24 hours is crucial for detecting fluid retention or worsening heart failure. This rapid weight gain indicates possible fluid overload, which can be a sign of worsening HF. Option A is not as critical as the timing of weighing can vary. Option C is important for tracking trends but does not emphasize the significance of a sudden weight gain. Option D is relevant for managing HF but does not address the immediate need for reporting rapid weight gain.

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