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. The nurse is caring for a client 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: Administering morphine is a priority intervention during the acute phase of myocardial infarction (MI). Morphine not only provides pain relief but also reduces myocardial oxygen demand, which is crucial in this situation. Choice B is incorrect because isometric exercises can increase myocardial oxygen demand and are not recommended during the acute phase of MI. Choice C is incorrect as elevating the head of the bed, not keeping the client flat, is preferred to reduce workload on the heart. Choice D is incorrect because fluid intake should be encouraged unless contraindicated, as adequate hydration is essential for cardiac function.

3. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

• A. Inform the UAP that suction is available at the bedside.
• B. Instruct the UAP to notify the nurse if the client chokes.
• C. Observe the UAP's ability to implement precautions during feeding.
• D. Ask the UAP about previous experience in performing this skill.

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

4. The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department?

• A. Before bedtime, at 2000
• B. After breakfast
• C. Before the evening meal
• D. After lunch

Correct answer: B

Rationale: Scheduling physical exercises after breakfast is the optimal choice for a client with Myasthenia Gravis. This timing allows the client to benefit from renewed energy levels after overnight rest and intake of morning nourishment, enhancing the effectiveness of the therapy session. Choices A (Before bedtime, at 2000) is not suitable as energy levels are likely lower at night, affecting the client's ability to engage effectively in physical exercises. Choices C (Before the evening meal) and D (After lunch) may not be ideal as the client may experience fatigue or weakness later in the day, making it harder to participate actively in therapy.

5. The nurse is assessing a client with hyperkalemia. Which finding is consistent with this electrolyte imbalance?

• A. Muscle weakness
• B. Decreased deep tendon reflexes
• C. Constipation
• D. Hypotension

Correct answer: A

Rationale: Muscle weakness is a common finding in clients with hyperkalemia. Hyperkalemia can lead to muscle weakness due to the effect of high potassium levels on muscle function. Decreased deep tendon reflexes (Choice B) are not typically associated with hyperkalemia; instead, hyperreflexia or increased reflexes may be observed. Constipation (Choice C) is not a common symptom of hyperkalemia. Hypotension (Choice D) is also not a typical finding in hyperkalemia; instead, hypertension or normal blood pressure may be present.

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