Nursing Elites

1. What are the key nursing interventions for a patient undergoing dialysis?

• A. Monitor fluid balance and administer heparin
• B. Monitor blood pressure and prevent clot formation
• C. Administer medications and monitor blood chemistry
• D. Provide dietary education and encourage protein intake

Correct answer: A

Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.

2. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

• A. Change the appliance daily
• B. Clean the stoma once a day
• C. Avoid changing the appliance for a week
• D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

3. A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Beneficence

Correct answer: D

Rationale: In this scenario, offering pain medication to a postoperative client before ambulation is an example of beneficence. Beneficence is the ethical principle related to promoting the well-being of the client, which includes providing pain relief to improve the client's comfort and facilitate their recovery. Fidelity (choice A) is about honoring commitments and being faithful to agreements, not directly related to pain management. Autonomy (choice B) refers to respecting the client's right to make decisions about their care, not specifically about pain medication administration. Justice (choice C) involves fairness and equality in healthcare resource allocation, not directly applicable in this situation.

4. When reviewing the medical record of a client with dementia, what should the nurse prioritize addressing?

• A. Mild confusion in the morning
• B. Restlessness and agitation
• C. Incontinence
• D. Frequent wandering at night

Correct answer: B

Rationale: When caring for clients with dementia, addressing restlessness and agitation is a priority as it can lead to distress, safety risks, and potential harm to the client or others. Restlessness and agitation are common behavioral symptoms of dementia and can indicate unmet needs, discomfort, or confusion. Managing these symptoms promptly can help improve the client's quality of life and prevent complications such as falls, injuries, or escalation of challenging behaviors. While other issues like mild confusion, incontinence, and wandering are also important to address, managing restlessness and agitation takes precedence due to its immediate impact on the client's well-being and safety.

5. A client with peripheral arterial disease (PAD) is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Apply lotion between the toes
• B. Wear shoes that fit properly
• C. Walk barefoot at home
• D. Apply ice to the feet daily

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes that fit properly.' In peripheral arterial disease (PAD), it is crucial to wear shoes that fit well to prevent foot injuries. Choice A is incorrect because applying lotion between the toes can increase the risk of infection. Choice C is incorrect since walking barefoot at home can lead to injuries, especially in individuals with PAD. Choice D is incorrect as applying ice to the feet daily can further reduce blood flow to the extremities, worsening the condition in PAD.

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