Nursing Elites

1. The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?

• A. the client who most recently rang their call bell
• B. the client who has been waiting the longest for their call bell to be answered
• C. the client who is in the most pain
• D. the client who may have a risk for an airway obstruction

Correct answer: D

Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority. Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.

2. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:

• A. measure intake and output.
• B. check albumin levels.
• C. monitor glucose levels.
• D. increase enteral feeding.

Correct answer: A

Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.

3. When are standard walkers typically used?

• A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
• B. When clients have poor balance, have a broken leg, or have experienced amputation.
• C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
• D. When clients have poor balance, have an autoimmune disease, or have weak arms.

Correct answer: C

Rationale: Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.

4. Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?

• A. Impaired Physical Mobility
• B. Dysreflexia
• C. Hypothermia
• D. Impaired Dentition

Correct answer: A

Rationale: The correct answer is 'Impaired Physical Mobility.' As Parkinson's disease progresses, clients may experience a shuffling gait and rigidity, leading to impaired physical mobility. This nursing diagnosis is relevant to address the functional limitations that may arise. 'Dysreflexia' is not typically associated with Parkinson's disease but rather with spinal cord injuries. 'Hypothermia' is a condition of abnormally low body temperature and is not a common complication of Parkinson's disease. 'Impaired Dentition' refers to dental issues and is not directly related to the progression of Parkinson's disease.

5. When working with elderly clients, the healthcare provider should keep in mind that falls are most likely to happen to the elderly who are:

• A. in their 80s.
• B. living at home.
• C. hospitalized.
• D. living on only Social Security income.

Correct answer: C

Rationale: The correct answer is 'hospitalized.' Elderly individuals are at a higher risk of falls, especially when they are in new environments like hospitals due to unfamiliarity with the surroundings, medications, and potential mobility challenges. Being in a hospital can disrupt their usual routines and increase the risk of falls. Choice A ('in their 80s') is not as directly related to the increased risk of falls in a hospital environment. Choice B ('living at home') is a common setting for the elderly but does not address the specific risk associated with being hospitalized. Choice D ('living on only Social Security income') is unrelated to the risk of falls based on the environment.

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