Nursing Elites

1. Which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind?

• A. Keep the room well-lit at all times.
• B. Speak to the client each time the nurse enters the room.
• C. Ensure the client wears glasses at all times.
• D. Provide written instructions in large print.

Correct answer: B

Rationale: The correct answer is to speak to the client each time the nurse enters the room. This intervention is crucial for orienting and reassuring the client, promoting safety, and facilitating communication. Keeping the room well-lit (Choice A) can be helpful but is not as essential as direct verbal communication. Ensuring the client wears glasses (Choice C) may not be feasible or necessary for someone who is legally blind. Providing written instructions in large print (Choice D) is not effective for a client with visual impairments.

2. The nurse is reviewing blood pressure readings for a group of clients on a medical unit. Which client is at the highest risk for complications related to hypertension?

• A. Post-menopausal Caucasian female who overeats and is 20% above her ideal body weight.
• B. Young adult Hispanic female who has hemoglobin at 11 g/dl (110 g/L) and drinks beer daily.
• C. Older adult who consumes a diet of smoked, cured, and pickled foods.
• D. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL (256.4 micromol/L).

Correct answer: D

Rationale: The correct answer is D. An elevated serum creatinine level indicates kidney damage, which significantly increases the risk of complications from hypertension. High blood pressure can damage the kidneys over time, leading to impaired kidney function. Choices A, B, and C do not directly correlate with increased risk of complications related to hypertension. Choice A focuses on obesity and overeating, Choice B on anemia and alcohol consumption, and Choice C on a diet high in sodium and nitrates, none of which are as directly related to hypertension complications as kidney damage.

3. What information should the nurse include in the teaching plan of a client diagnosed with GERD?

• A. Sleep without using pillows
• B. Opt for five small meals throughout the day instead of three full meals with no snacks
• C. Minimize symptoms by wearing loose, comfortable clothing
• D. Engage in low-impact exercises like walking or swimming

Correct answer: C

Rationale: The correct answer is C: 'Minimize symptoms by wearing loose, comfortable clothing.' Wearing loose, comfortable clothing can help reduce pressure on the abdomen, which can alleviate GERD symptoms. Option A is incorrect as sleeping without using pillows is not a recommended practice for managing GERD. Option B is incorrect because it suggests adjusting food intake to five small meals throughout the day instead of three full meals with no snacks, which may not be suitable for everyone with GERD. Option D is incorrect as avoiding participation in any aerobic exercise program is not a standard recommendation for managing GERD; in fact, engaging in low-impact exercises like walking or swimming can be beneficial.

4. A client is currently receiving an infusion labeled as 5% dextrose injection 500 ml with heparin sodium 25,000 units at 14 mL/hour per pump. A prescription is received to change the rate of the infusion to heparin 1,000 units/hour. How many ml/hour should the nurse program the infusion pump?

• A. 16 ml/hour.
• B. 18 ml/hour.
• C. 20 ml/hour.
• D. 22 ml/hour.

Correct answer: C

Rationale: To deliver 1,000 units/hour from a solution with 25,000 units in 500 ml, the rate should be set to 20 ml/hour. This is calculated by determining that the solution has 50 units/ml (25,000 units / 500 ml = 50 units/ml) and then dividing the required 1,000 units/hour by 50 units/ml, resulting in 20 ml/hour. Therefore, the nurse should program the infusion pump to deliver heparin at 20 ml/hour. Choices A, B, and D are incorrect as they do not align with the calculated rate of 20 ml/hour.

5. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

• A. Assist with personal care, but leave oral care for the nurse to complete.
• B. Provide a soft bristle brush for the client to use during oral care.
• C. Use alcohol-based mouthwash to clean the ulcers.
• D. Apply an antifungal cream to the mouth ulcers.

Correct answer: B

Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.

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