Nursing Elites

1. When providing care for a client receiving palliative care for terminal cancer, what should the nurse prioritize?

• A. Pain management
• B. Arranging family visits
• C. Discussing advance directives
• D. Providing nutritional support

Correct answer: A

Rationale: When caring for a client receiving palliative care for terminal cancer, the nurse should prioritize pain management. Effective pain management is crucial in enhancing the quality of life for terminally ill patients. While arranging family visits and discussing advance directives are important aspects of care, pain management takes precedence in providing comfort and alleviating suffering. Nutritional support is essential but may be of lesser priority compared to pain management in this context.

2. A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

• A. Increase wall suction to eliminate fluctuation in the water seal.
• B. Give blood from the collection chamber as autotransfusion.
• C. Add sterile water to the suction control chamber.
• D. Manipulate blood in tubing to drain into chamber.

Correct answer: C

Rationale: The correct intervention for the nurse to implement is to add sterile water to the suction control chamber. This action helps maintain the proper functioning of the chest tube system by regulating the negative pressure. Increasing wall suction is not recommended as it could lead to excessive negative pressure. Giving blood from the collection chamber as autotransfusion is inappropriate and poses a risk of complications such as air embolism. Manipulating blood in the tubing is also unsafe as it could introduce air into the system, increasing the risk of complications for the client.

3. A client with a diagnosis of anemia is being discharged with a prescription for ferrous sulfate. What should the nurse include in the teaching plan?

• A. Take the medication with milk to enhance absorption
• B. Expect stools to be dark in color
• C. Take the medication before bedtime
• D. Avoid foods high in vitamin C

Correct answer: B

Rationale: The correct answer is B: 'Expect stools to be dark in color.' Dark stools are a common side effect of iron supplementation due to the unabsorbed iron, and this is not a cause for concern. Choice A is incorrect because taking iron with milk can decrease its absorption due to calcium binding. Choice C is incorrect as there are no specific recommendations to take ferrous sulfate before bedtime. Choice D is also incorrect as vitamin C actually enhances iron absorption and should not be avoided.

4. During the assessment of a client who has suffered a stroke, what finding would indicate a complication?

• A. Difficulty swallowing
• B. A slight headache
• C. High blood pressure
• D. Muscle weakness on one side

Correct answer: A

Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.

5. The nurse explains the 2-week dosage prescription of prednisone (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule?

• A. Decrease the dosage daily as prescribed
• B. Monitor oral temperature daily
• C. Take the prednisone with meals
• D. Return for blood glucose monitoring in one week

Correct answer: A

Rationale: The correct answer is A: 'Decrease the dosage daily as prescribed.' Tapering the dosage of prednisone is crucial to prevent withdrawal symptoms and minimize the side effects of corticosteroid therapy. Decreasing the dosage gradually over time allows the body to adjust and reduces the risk of adrenal insufficiency. Choices B, C, and D are incorrect. Monitoring oral temperature daily, taking prednisone with meals, or returning for blood glucose monitoring in one week are not specific to the dosing schedule of prednisone for poison ivy treatment.

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