Nursing Elites

1. A client complains of difficulty swallowing when the nurse tries to administer capsule medication. Which of the following measures should the nurse take?

• A. Dissolve the capsule in a glass of water
• B. Break the capsule and give the contents with applesauce
• C. Check the availability of a liquid preparation
• D. Crush the capsule and place it under the tongue

Correct answer: C

Rationale: When a client has difficulty swallowing capsule medication, the nurse should check the availability of a liquid preparation. This is a safer approach and ensures that the medication's integrity is maintained, providing an alternative form that is easier for the client to take. Dissolving the capsule in water (choice A) may alter the medication's effectiveness, breaking the capsule and mixing the contents with applesauce (choice B) is not recommended as it may cause an unpleasant taste, and crushing the capsule and placing it under the tongue (choice D) can be unsafe and affect the medication's absorption.

2. What is the best position for examining the rectum?

• A. Prone
• B. Sim's
• C. Knee-chest
• D. Lithotomy

Correct answer: C

Rationale: The knee-chest position is the most optimal position for examining the rectum. In this position, the patient kneels on the examination table with their chest resting on it, creating a straight line from the head to the lower back. This position allows for easier access and visualization of the rectal area, making it the preferred choice for rectal examinations. Prone position (choice A) is lying face down and is not ideal for rectal exams as it does not provide good access. Sim's position (choice B) is lying on the left side with the right knee and thigh flexed, also not ideal for rectal exams. Lithotomy position (choice D) is lying on the back with legs flexed and feet in stirrups, primarily used for gynecological exams and surgery, not for rectal examinations.

3. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

• A. Apply a vest restraint if self-extubation is attempted.
• B. Monitor ventilator settings every 8 hours.
• C. Document tube placement in centimeters at the angle of the jaw.
• D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

4. If a patient asks the nurse for her opinion about a particular physician and the nurse replies that the physician is incompetent, the nurse could be held liable for:

• A. Slander
• B. Libel
• C. Assault
• D. Respondent superior

Correct answer: A

Rationale: In this scenario, if the nurse makes a false verbal statement about the physician being incompetent, it is considered slander. Slander is the act of making defamatory spoken statements or gestures. Libel, on the other hand, refers to defamatory statements that are written or published. Assault involves the threat of physical harm, and respondent superior is a legal doctrine holding an employer responsible for the actions of an employee in the course of employment.

5. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:

• A. A ham and Swiss cheese sandwich on whole wheat bread
• B. Mashed potatoes and broiled chicken
• C. A tossed salad with oil and vinegar and olives
• D. Chicken bouillon

Correct answer: B

Rationale: The correct answer is B: Mashed potatoes and broiled chicken. Both mashed potatoes and broiled chicken are typically low in sodium content, making them suitable choices for a 500-mg low sodium diet. The other options, such as a ham and Swiss cheese sandwich on whole wheat bread, a tossed salad with oil and vinegar and olives, and chicken bouillon, may contain higher amounts of sodium and are not typically recommended for a low sodium diet.

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