Nursing Elites

1. The wife of an older adult man who has had diabetes mellitus for the past 10 years reports to the home health nurse that her husband fell yesterday while taking his daily walk in the neighborhood. He has a bruised hand and a small abrasion on his left knee. The nurse assesses that his neurologic vital signs are stable. To reduce the risk for future falls, which assessment is most important for the nurse to obtain?

• A. current blood sugar level
• B. degree of paresthesia in feet
• C. wound healing of knee abrasion
• D. A1c glycosylated hemoglobin

Correct answer: B

Rationale: Assessing for paresthesia (numbness or tingling) in the feet is crucial in this scenario as it can help determine if the client has a loss of sensation, which increases the risk of falls. Paresthesia is a common complication of diabetes that can lead to decreased sensation and proprioception in the feet, contributing to balance issues and an increased risk of falls. Monitoring for paresthesia allows the nurse to assess the extent of sensory impairment and implement appropriate interventions to prevent future falls. While monitoring blood sugar levels (choice A) and A1c levels (choice D) are important in managing diabetes, in this case, assessing paresthesia takes precedence due to its direct impact on fall risk. Similarly, while monitoring the wound healing of the knee abrasion (choice C) is important for overall wound care, it is not directly related to reducing the risk of future falls in this situation.

2. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?

• A. Jaundice.
• B. Ascites.
• C. Peripheral edema.
• D. Spider angiomas.

Correct answer: D

Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.

3. The healthcare provider is assessing a client who is receiving total parenteral nutrition (TPN). Which finding requires immediate intervention?

• A. Blood glucose level of 150 mg/dL.
• B. Weight gain of 2 pounds in 24 hours.
• C. Decreased urine output.
• D. Temperature of 100.3°F (37.9°C).

Correct answer: C

Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3°F (37.9°C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.

4. A client with a history of chronic kidney disease is receiving erythropoietin therapy. Which finding indicates that the therapy is effective?

• A. Hemoglobin of 12 g/dL.
• B. Reticulocyte count of 1%.
• C. Blood pressure of 130/80 mm Hg.
• D. Serum ferritin level of 100 ng/mL.

Correct answer: A

Rationale: The correct answer is A. A hemoglobin level of 12 g/dL is an indicator of effective erythropoietin therapy as it shows an increase in red blood cell production. Reticulocyte count (choice B) reflects the bone marrow's response to anemia but does not directly confirm the effectiveness of erythropoietin therapy. Blood pressure (choice C) and serum ferritin level (choice D) are not specific indicators of the effectiveness of erythropoietin therapy for chronic kidney disease.

5. An 80-year-old client is given morphine sulfate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?

• A. Nonsteroidal anti-inflammatory agents.
• B. Antihistamines.
• C. Tricyclic antidepressants.
• D. Antibiotics.

Correct answer: C

Rationale: The correct answer is C: Tricyclic antidepressants. Drugs with anticholinergic properties, such as tricyclic antidepressants, can exacerbate urinary retention associated with opioids in older clients. Nonsteroidal anti-inflammatory agents (Choice A) do not typically cause urinary retention. Antihistamines (Choice B) may cause urinary retention but are not the primary concern in this scenario. Antibiotics (Choice D) are not associated with an increased risk of urinary retention compared to tricyclic antidepressants.

Similar Questions