Nursing Elites

1. Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?

• A. Wear long-sleeved clothing when outdoors
• B. Report the onset of sore throat
• C. Eat plenty of potassium-rich food
• D. Change the position slowly

Correct answer: D

Rationale: The correct instruction for an elderly client taking both an ACE inhibitor and a calcium channel blocker is to change positions slowly. Both medications can lead to orthostatic hypotension, a sudden drop in blood pressure when changing positions, which can increase the risk of falls. Instructing the client to change positions slowly helps prevent falls. Wearing long-sleeved clothing when outdoors does not directly relate to the medication combination. Reporting the onset of a sore throat is important for monitoring potential side effects but is not specific to these medications. While potassium levels should be monitored with ACE inhibitors, eating plenty of potassium-rich foods without guidance can lead to hyperkalemia, a potential side effect of ACE inhibitors.

2. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client?

• A. Black
• B. Yellow
• C. Green
• D. Red

Correct answer: D

Rationale: The correct answer is D: Red. The client's vital signs indicate critical condition with a high pulse and low blood pressure, suggesting shock. A red tag is used to identify patients who require immediate attention and should be prioritized for treatment. Choice A, Black, is incorrect as it is typically used for deceased or expectant clients. Choice B, Yellow, is used for clients with non-life-threatening injuries who require medical care but can wait. Choice C, Green, is for clients with minor injuries who can wait the longest for treatment. Therefore, in this scenario, the client's condition warrants a red triage tag for immediate attention.

3. The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?

• A. Administer the 20 Units of Humulin R subcutaneously as prescribed
• B. Ask the girl if she will be eating her breakfast this morning
• C. Discuss changing the insulin prescription to Lispro with the healthcare provider
• D. Explain to the mother the importance of eating the scheduled meals

Correct answer: B

Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.

4. Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement?

• A. Require cross-training for obstetrics for other nurses
• B. Propose a method for self-staffing labor and delivery
• C. Remind nurses that floating is an administrative policy
• D. Encourage nurses to share their feelings with administration

Correct answer: B

Rationale: The best action for the nurse-manager to implement is to propose a method for self-staffing labor and delivery. This approach allows nurses to manage their schedules, ensuring a fair balance of workloads. Requiring cross-training for obstetrics for other nurses (Choice A) may not be feasible or necessary for all units. Reminding nurses that floating is an administrative policy (Choice C) does not address the underlying issue of workload balance. Encouraging nurses to share their feelings with administration (Choice D) may not lead to a concrete solution for the unequal floating concerns.

5. A client with chronic renal failure is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that the client's abdomen is distended. What action should the nurse take first?

• A. Turn the client from side to side
• B. Increase the dwell time of the dialysis
• C. Reposition the client
• D. Milk the catheter

Correct answer: A

Rationale: The correct first action for the nurse to take is turning the client from side to side. This helps to facilitate drainage in peritoneal dialysis. Turning the client can aid in redistributing the dialysate and promoting better drainage. Increasing the dwell time of the dialysis (choice B) may not address the immediate issue of inadequate drainage. Repositioning the client (choice C) might not be as effective as turning the client from side to side. Milking the catheter (choice D) is not recommended as it can lead to complications. In this situation, the priority is to facilitate drainage to address the distended abdomen.

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