Nursing Elites

1. What are the key factors in assessing a patient's fall risk?

• A. Assess the patient's age and mobility
• B. Evaluate the patient's medication list for sedatives
• C. Assess the patient's vision and hearing
• D. Check for recent falls and cognitive impairment

Correct answer: A

Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.

2. A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?

• A. Yankauer catheter
• B. Bulb syringe
• C. Suction catheter
• D. Sterile gloves

Correct answer: A

Rationale: The correct answer is A: Yankauer catheter. The Yankauer catheter is specifically designed for oral suctioning, making it the most appropriate choice for this task. Choice B, the Bulb syringe, is typically used for suctioning small amounts of liquid from the nose or mouth. Choice C, the Suction catheter, is more commonly used for deep suctioning in the trachea or bronchi. Choice D, Sterile gloves, are necessary for infection control but are not the primary supply used for oral suctioning.

3. What are the key differences between hypoglycemia and hyperglycemia?

• A. Hypoglycemia: Sweating, trembling; Hyperglycemia: Frequent urination, thirst
• B. Hypoglycemia: Increased thirst; Hyperglycemia: Sweating, confusion
• C. Hypoglycemia: Increased appetite; Hyperglycemia: Blurred vision
• D. Hypoglycemia: Dizziness; Hyperglycemia: Low blood pressure

Correct answer: A

Rationale: Hypoglycemia typically presents with sweating and trembling, while hyperglycemia is characterized by frequent urination and thirst. Therefore, the correct key differences between hypoglycemia and hyperglycemia are that hypoglycemia includes symptoms like sweating and trembling, while hyperglycemia involves symptoms such as frequent urination and thirst. Choices B, C, and D are incorrect because they do not accurately represent the characteristic symptoms of hypoglycemia and hyperglycemia, as stated in the question.

4. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?

• A. Administer PRN haloperidol (Haldol) to decrease the need to walk
• B. Assess the client's gait for steadiness
• C. Restrain the client in a geriatric chair
• D. Administer PRN lorazepam (Ativan) to provide sedation

Correct answer: B

Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.

5. What is the first step in assessing a patient with suspected stroke?

• A. Check for facial droop
• B. Assess speech clarity
• C. Perform a neurological assessment
• D. Call for emergency assistance

Correct answer: D

Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.

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