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. A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

• A. Assess the client’s need for pain medication
• B. Document the impending signs of death
• C. Inform the nurse manager of the client’s status
• D. Communicate the client’s status to the chaplain

Correct answer: A

Rationale: Assessing the client’s need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.

3. When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

• A. 42
• B. 38
• C. 48
• D. 50

Correct answer: A

Rationale: By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.

4. The nurse is assessing a first-day postpartum client. Which finding is most indicative of a postpartum infection?

• A. Oral temperature of 100.2°F (37.9°C)
• B. Blood pressure of 122/74 mmHg
• C. Moderate amount of foul-smelling lochia
• D. White blood count of 19,000/mm³ (19x10^9/L SI units)

Correct answer: C

Rationale: A foul-smelling lochia is indicative of a postpartum infection, such as endometritis. Foul-smelling lochia suggests the presence of infection due to the breakdown of tissue by bacteria, leading to the malodor. An oral temperature elevation and an elevated white blood cell count are nonspecific and can be present in various conditions other than postpartum infections, making them less indicative. A blood pressure within normal limits is not typically associated with postpartum infections.

5. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

• A. Intravenous administration of thyroid hormones
• B. Oral administration of hypnotic agents
• C. Intravenous bolus of hydrocortisone
• D. Subcutaneous administration of vitamin K

Correct answer: A

Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.

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