Nursing Elites

1. What should be done to minimize the risk of injury for a client with dementia?

• A. Ensure the client has consistent caregivers
• B. Dim the lights in the client's room
• C. Allow the client to sleep with the bedrails raised
• D. Encourage family members to stay with the client

Correct answer: A

Rationale: The correct answer is to ensure the client has consistent caregivers. This helps reduce confusion and stress for clients with dementia by providing familiarity and routine. Dimming the lights in the client's room (Choice B) may not directly address the risk of injury. Allowing the client to sleep with the bedrails raised (Choice C) can pose a risk if not properly monitored. Encouraging family members to stay with the client (Choice D) may not always be feasible and may not provide the necessary professional support and consistency that consistent caregivers can offer.

2. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.
• D. Set up the sterile field 5 cm (2 in) above waist level.

Correct answer: A

Rationale: To maintain the sterility of the field, the nurse should place the cap from the solution sterile side up on a clean surface. This action helps prevent contamination. Choice B is incorrect because opening the outermost flap toward the body increases the risk of introducing contaminants onto the sterile field. Choice C is incorrect as the sterile dressing should be placed at least 2.5 cm (1 in) from the edge of the sterile field to prevent accidental contamination. Choice D is incorrect because setting up the sterile field above waist level could lead to inadvertent contact and compromise the field's sterility.

3. What are common signs of hypoglycemia?

• A. Shakiness or Tremors
• B. Sweating
• C. Hunger
• D. Confusion or Irritability

Correct answer: A

Rationale: The correct signs of hypoglycemia include shakiness or tremors, sweating, and hunger. These symptoms indicate low blood sugar levels. Confusion or irritability are more associated with severe hypoglycemia, while the immediate treatment for hypoglycemia involves providing a source of glucose to raise blood sugar levels quickly.

4. What is the priority for a client with dehydration?

• A. Administer antiemetics to prevent nausea
• B. Monitor electrolyte levels to prevent imbalances
• C. Administer oral rehydration solutions
• D. Administer intravenous fluids

Correct answer: B

Rationale: The priority for a client with dehydration is to monitor electrolyte levels to prevent imbalances. Dehydration can lead to electrolyte disturbances, which can have serious consequences. Administering antiemetics (Choice A) may help with nausea but does not address the root cause of dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels is crucial in managing dehydration. Administering intravenous fluids (Choice D) is important in severe cases of dehydration, but monitoring electrolytes should come first to assess the extent of the imbalance and guide fluid replacement therapy effectively.

5. Which instruction should be emphasized for a client with diabetes being discharged?

• A. Check blood sugar once daily
• B. Take insulin before meals as prescribed
• C. Monitor glucose levels weekly
• D. Eat carbohydrate-rich meals to maintain glucose levels

Correct answer: B

Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.

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