Nursing Elites

1. A client with a history of stroke presents with dysphagia. What is the most important nursing intervention to prevent aspiration?

• A. Encourage the client to drink water between meals
• B. Position the client in a high-Fowler's position during meals
• C. Provide the client with thickened liquids
• D. Allow the client to eat quickly

Correct answer: B

Rationale: The correct answer is B: Position the client in a high-Fowler's position during meals. Placing the client in a high-Fowler's position (sitting upright at a 90-degree angle) helps reduce the risk of aspiration by ensuring that the airway is protected during swallowing. This position facilitates easier swallowing and decreases the likelihood of food or liquids entering the respiratory tract. Encouraging the client to drink water between meals (choice A) does not directly address the risk of aspiration during meals. Providing thickened liquids (choice C) may be necessary for some patients with dysphagia but is not the most important intervention to prevent aspiration. Allowing the client to eat quickly (choice D) without proper positioning and precautions can increase the risk of aspiration.

2. 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.

3. To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)

• A. Posterior tibial artery
• B. Radial artery
• C. External iliac artery
• D. Dorsalis pedis artery

Correct answer: D

Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.

4. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

5. A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

• A. Administer morphine for pain relief
• B. Encourage the client to perform isometric exercises
• C. Position the client flat in bed
• D. Restrict fluid intake

Correct answer: A

Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.

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