Nursing Elites

1. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow-up rather than delegate care to the nursing assistant?

• A. Has had a change in respiratory rate with an increase of 2 breaths
• B. Has had a change in heart rate with an increase of 10 beats
• C. Was minimally responsive to voice and touch
• D. Has had a blood pressure change with a drop of 8 mmHg systolic

Correct answer: C

Rationale: A change in responsiveness, as indicated by being minimally responsive to voice and touch, suggests a potential acute issue that requires immediate nursing assessment and intervention rather than delegation. Changes in vital signs (choices A, B, D) can be important but do not always indicate an immediate need for nursing intervention compared to a change in responsiveness.

2. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

3. A male client with HIV on saquinavir and other antiretrovirals reports increased hunger and thirst but weight loss. Which action should the nurse take?

• A. Use a glucometer to assess capillary glucose.
• B. Explain to the client that an increased dose of medication is needed.
• C. Reassure the client that weight will improve as viral load decreases.
• D. Teach the client how to measure his weight accurately.

Correct answer: A

Rationale: Increased thirst and hunger while losing weight may indicate hyperglycemia, a common side effect of saquinavir and other antiretrovirals. Using a glucometer to assess capillary glucose levels is essential to evaluate for hyperglycemia. Choice B is incorrect because increasing the dose of medication without assessing blood glucose levels can be dangerous. Choice C is incorrect because weight loss may not necessarily improve with viral load reduction and doesn't address the immediate concern of hyperglycemia. Choice D is irrelevant to the presenting symptoms and should not be a priority over assessing for hyperglycemia.

4. The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?

• A. Question the client about the frequency of falls.
• B. Request the client to lie still during the assessment.
• C. Ask how often episodes of sundowning are experienced.
• D. Assist the client with values clarification about end-of-life care.

Correct answer: A

Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.

5. An adult male is brought to the emergency department following a motorcycle accident, presenting with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

• A. Rebound abdominal tenderness.
• B. Diminished bilateral breath sounds.
• C. Rib pain with deep inspiration.
• D. Nausea with projectile vomiting.

Correct answer: D

Rationale: In this scenario, the patient's presentation with periorbital bruising and bloody ear drainage suggests a basilar skull fracture. Projectile vomiting, as described in choice D, is concerning for increased intracranial pressure due to the skull fracture. This finding warrants immediate intervention to prevent further neurological compromise. Choices A, B, and C are not the priority in this situation. Rebound abdominal tenderness (choice A) is indicative of intra-abdominal injury but is not as urgent as managing potential intracranial issues. Diminished breath sounds (choice B) and rib pain with deep inspiration (choice C) may suggest underlying chest injuries, which need attention but are not as immediately life-threatening as increased intracranial pressure.

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