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. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?

• A. Administer an epinephrine injection
• B. Call for immediate medical help
• C. Monitor airway, breathing, and circulation
• D. All of the above

Correct answer: A

Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.

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 new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?

• A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits
• B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina
• C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn
• D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection

Correct answer: D

Rationale: The correct answer is D because informing about state law emphasizes the legal requirement and public health rationale behind prophylactic eye treatment to prevent serious infections like gonorrheal or chlamydial ophthalmic infection. Choices A, B, and C are incorrect. Choice A focuses on staphylococcus infection, which is not the primary concern addressed by the prophylactic ointment. Choice B mentions a specific infection acquired from the mother's infected vagina, which is not the main reason for the ophthalmic ointment. Choice C discusses tear duct obstruction and dry eyes, which are not the primary concerns addressed by the prophylactic ointment.

5. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?

• A. Restrict sodium intake
• B. Encourage high-protein meals
• C. Increase fluid intake
• D. Administer diuretics as prescribed

Correct answer: D

Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.

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