Nursing Elites

1. A 4-year-old child is returned to the room following a tonsillectomy and adenoidectomy. Which of the following assessments would require the nurse's immediate attention?

• A. Frequent swallowing
• B. Coughing
• C. Slow breathing
• D. Tachycardia

Correct answer: A

Rationale: In a post-tonsillectomy and adenoidectomy patient, frequent swallowing is a crucial assessment that requires immediate attention by the nurse. Frequent swallowing can indicate bleeding, a complication that needs urgent intervention. Coughing may be expected due to irritation from the surgery but is not as concerning as potential bleeding. Slow breathing and tachycardia are not typically immediate concerns following this type of surgery.

2. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?

• A. Increase the client's sedative dose
• B. Encourage the client to express her feelings and provide emotional support
• C. Initiate breathing techniques to manage anxiety
• D. Administer anxiolytic medication to calm the client

Correct answer: B

Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.

3. A client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). What should the nurse monitor for?

• A. Monitor for signs of liver toxicity.
• B. Assess for gastrointestinal side effects, such as nausea or diarrhea.
• C. Monitor for signs of infection, such as fever or sore throat.
• D. Administer DMARDs with meals to prevent gastrointestinal upset.

Correct answer: C

Rationale: Correct Answer: Monitoring for signs of infection, such as fever or sore throat, is crucial when a client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). DMARDs can suppress the immune system, making individuals more susceptible to infections. Early detection of infections allows for prompt treatment and helps prevent complications. Choices A, B, and D are incorrect because while liver toxicity and gastrointestinal side effects are possible side effects of DMARDs, monitoring for signs of infection takes priority due to the increased risk of infections associated with these medications.

4. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

• A. Accompanying a client who self-administers insulin
• B. Cleansing and dressing a small decubitus ulcer
• C. Monitoring a client's response to passive range of motion exercises
• D. Applying and caring for a client's rectal pouch

Correct answer: D

Rationale: The correct answer is D because tasks like applying and caring for a client's rectal pouch are within the UAP's scope of practice, as they do not require clinical judgment. Choices A, B, and C involve more complex assessments or interventions that require clinical judgment and should be performed by licensed nursing staff.

5. A client with Alzheimer's disease is prescribed donepezil. What is the most important teaching point?

• A. Take the medication as directed for best results.
• B. Report any unusual changes in behavior.
• C. This medication helps improve cognitive function.
• D. This medication is not a cure for Alzheimer's disease.

Correct answer: C

Rationale: The most important teaching point for a client prescribed donepezil is that it helps improve cognitive function. While it is important to take the medication as directed for best results (choice A) and report any unusual changes in behavior (choice B), the key point is that donepezil is not a cure for Alzheimer's disease (choice D). Therefore, the correct answer is C.

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