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. Which nonfood item is the most common cause of respiratory arrest in young children?

• A. Broken rattles
• B. Buttons
• C. Pacifiers
• D. Latex balloons

Correct answer: D

Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.

3. A client with hypothyroidism is taking levothyroxine (Synthroid). Which symptom should prompt the nurse to notify the healthcare provider?

• A. Weight gain
• B. Bradycardia
• C. Nervousness and tremors
• D. Fatigue

Correct answer: C

Rationale: The correct answer is C: Nervousness and tremors. These symptoms may indicate hyperthyroidism resulting from excessive dosing of levothyroxine. Weight gain (Choice A) is a common symptom of hypothyroidism and may indicate undertreatment or inadequate dosing. Bradycardia (Choice B) is a symptom of hypothyroidism and may improve with levothyroxine therapy; it does not typically indicate an urgent need for healthcare provider notification. Fatigue (Choice D) is a symptom of hypothyroidism and can persist even with levothyroxine treatment, so it is not a symptom that would require immediate notification of the healthcare provider.

4. A client with chronic kidney disease is being evaluated for dialysis. Which laboratory value would be most concerning to the nurse?

• A. Hemoglobin 9.5 g/dL
• B. Potassium 6.2 mEq/L
• C. Creatinine 3.5 mg/dL
• D. BUN 50 mg/dL

Correct answer: B

Rationale: The correct answer is B: Potassium 6.2 mEq/L. In chronic kidney disease, the kidneys struggle to regulate potassium levels, leading to hyperkalemia. A potassium level of 6.2 mEq/L is dangerously high and can cause life-threatening cardiac arrhythmias. Hemoglobin of 9.5 g/dL may indicate anemia, which is common in chronic kidney disease but is not immediately life-threatening. Creatinine and BUN levels are markers of kidney function; although elevated levels indicate kidney impairment, they are not acutely life-threatening like severe hyperkalemia.

5. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed
• B. Perform chest physiotherapy
• C. Encourage increased fluid intake
• D. Provide humidified oxygen

Correct answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

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