Nursing Elites

1. Which nursing intervention is most appropriate for managing delirium in an elderly patient?

• A. Keeping the room brightly lit
• B. Administering sedatives as needed
• C. Encouraging family presence
• D. Restricting fluids

Correct answer: C

Rationale: Encouraging family presence is the most appropriate intervention for managing delirium in elderly patients. This intervention provides orientation, reassurance, and comfort, which can help reduce confusion and anxiety, thus aiding in managing delirium. Keeping the room brightly lit (Choice A) may worsen delirium as it can disrupt the patient's sleep-wake cycle. Administering sedatives (Choice B) should be avoided unless absolutely necessary due to the risk of worsening delirium. Restricting fluids (Choice D) is not a recommended intervention for managing delirium, as hydration is important for overall patient well-being.

2. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?

• A. The newborn is infected with an infectious blood-borne disease
• B. The newborn needs phototherapy for physiologic jaundice
• C. The mother's Rh antibodies are present in the neonatal blood
• D. The mother no longer needs Rho immune globulin injections

Correct answer: C

Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.

3. During a fire incident in a long-term care facility's kitchen, which task is most crucial for the PN to perform instead of delegating to UAP?

• A. Close the doors to all residents' rooms
• B. Offer comfort and reassurance to each resident
• C. Identify the method for transporting and evacuating each resident
• D. Provide blankets to each resident for use during evacuation

Correct answer: C

Rationale: During a fire emergency, the most critical task for the PN is to identify the method for transporting and evacuating each resident. This task ensures a safe and organized evacuation plan, which is essential for everyone's safety. Delegating this responsibility to an unlicensed assistive personnel (UAP) may lead to errors or delays in the evacuation process. Closing doors to residents' rooms (Choice A) can help contain the fire but is not as urgent as planning the evacuation. While offering comfort and reassurance (Choice B) is important, it should not take precedence over ensuring a safe evacuation. Providing blankets (Choice D) is helpful but does not directly address the primary concern of safely evacuating residents.

4. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

• A. Glucose should be taken if I have a fruity breath odor.
• B. Glucose should be taken if I am urinating more than usual.
• C. Glucose should be taken if I have blurred vision.
• D. Glucose should be taken if I develop shakiness.

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

5. When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the nurse to perform instead of assigning to a UAP?

• A. Close the doors to all residents' rooms
• B. Offer comfort and reassurance to each resident
• C. Identify the method for transporting and evacuating each resident
• D. Provide blankets to each resident for use during evacuation

Correct answer: C

Rationale: During a fire emergency in a long-term care facility, the most critical task for the nurse is to identify the method for transporting and evacuating each resident. This task requires quick decision-making and critical thinking, which are essential in ensuring the safety and well-being of the residents. Closing the doors to residents' rooms (Choice A) can help contain the fire but should not be the nurse's top priority. While offering comfort and reassurance (Choice B) is important, the immediate focus should be on ensuring safe evacuation. Providing blankets (Choice D) is also important but comes after ensuring safe transportation and evacuation plans are in place.

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