Nursing Elites

1. A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client’s plan of care?

• A. Encourage speaking slowly and articulating words
• B. Sit upright and flex chin forward while swallowing
• C. Position a communication board at the bedside
• D. Provide feeding utensils with large grip handles

Correct answer: B

Rationale: The correct intervention for a client with ALS experiencing difficulty swallowing and articulating words is to sit upright and flex the chin forward while swallowing. This position helps manage dysphagia associated with ALS by facilitating the swallowing process. Encouraging speaking slowly and articulating words (Choice A) may be helpful for speech clarity but does not address the swallowing issue. Positioning a communication board (Choice C) would not directly address the swallowing difficulty. Providing feeding utensils with large grip handles (Choice D) is not the priority intervention for managing dysphagia in ALS.

2. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “What do you think you’re doing?” How should the nurse respond?

• A. “I cannot give you this medication until you calm down.”
• B. “This shot will help relieve the pain in your feet.”
• C. “Would you prefer to learn to administer your own shot?”
• D. “You will feel calmer and less jittery after this shot.”

Correct answer: B

Rationale: The correct response is to provide a relevant explanation to the client. Choice B, “This shot will help relieve the pain in your feet,” is the best answer because it directly addresses the client's concern about the purpose of the medication. By explaining the potential benefit of the injection, the nurse can alleviate the client's anxiety and increase their cooperation during the procedure. Choice A is incorrect as it dismisses the client's question and may escalate the situation. Choice C is not suitable as it deviates from addressing the client's immediate query. Choice D is incorrect because it fails to specifically address the client's concern regarding the medication's purpose.

3. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)

• A. 0.4
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the volume to administer, use the formula: Desired dose (220,000 units) / Dose on hand (600,000 units) x Volume of the available dose (1 ml). This results in 0.4 ml to be administered. Choice A is correct. Choice B, C, and D are incorrect as they are not provided.

4. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete before leaving the delivery room?

• A. Obtain the infant's vital signs.
• B. Observe the infant latching onto the breast.
• C. Administer a vitamin K injection.
• D. Place the ID bands on the infant and mother.

Correct answer: D

Rationale: Placing ID bands on the infant and mother is crucial to ensure correct identification and prevent mix-ups. This step is essential for maintaining proper identification of the newborn and the mother, facilitating safe care delivery. Before leaving the delivery room, ensuring proper identification is a priority to prevent any errors. Obtaining the infant's vital signs may be important but does not take precedence over ensuring correct identification. Observing the infant latching onto the breast is crucial for breastfeeding initiation but can be done after proper identification. Administering a vitamin K injection is also important but should not delay the immediate identification process.

5. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?

• A. Headache
• B. Pruritus
• C. Nausea
• D. Stridor

Correct answer: D

Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.

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