Nursing Elites

1. Why is a client with ascites scheduled for a paracentesis procedure?

• A. To diagnose liver disease
• B. To relieve abdominal pressure
• C. To assess kidney function
• D. To reduce blood pressure

Correct answer: B

Rationale: The correct answer is B: "To relieve abdominal pressure." Paracentesis is performed to drain accumulated fluid in the peritoneal cavity, providing symptomatic relief for clients with ascites. Choice A is incorrect because paracentesis is not a diagnostic procedure for liver disease. Choice C is incorrect as assessing kidney function would typically involve different procedures. Choice D is incorrect as paracentesis does not directly impact blood pressure.

2. When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?

• A. Brudzinski's sign
• B. Positive Babinski reflex
• C. Kernig's sign
• D. Both A and C

Correct answer: D

Rationale: Both Brudzinski's sign and Kernig's sign are classic signs of meningeal irritation, commonly associated with meningitis. Brudzinski's sign is positive when flexing the neck causes involuntary flexion of the hips and knees due to irritation of the meninges. Kernig's sign is positive when there is pain and resistance with knee extension after hip flexion, indicating meningeal irritation or inflammation. The Babinski reflex, mentioned in choice B, is a test used to assess upper motor neuron damage and is not specific to meningitis. Therefore, choices A and C are the correct options as they are indicative of meningeal irritation in a suspected case of meningitis.

3. A patient who is receiving chemotherapy for breast cancer develops thrombocytopenia. What should the nurse include in the care plan?

• A. Encourage light exercise.
• B. Avoid intramuscular injections.
• C. Do not administer aspirin.
• D. Use a soft toothbrush for oral care.

Correct answer: B

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. To minimize this risk, patients with thrombocytopenia should avoid activities that can cause injury or bleeding, such as intramuscular injections. Encouraging light exercise can be beneficial, as it promotes circulation without increasing the risk of trauma. However, avoiding intramuscular injections is crucial to prevent bleeding episodes. Aspirin should be avoided as it can further impair platelet function, exacerbating the condition. Using a soft toothbrush for oral care is recommended to prevent gum bleeding in patients with thrombocytopenia.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client's safety?

• A. Increase the oxygen flow rate to 6 liters/minute if the client is short of breath.
• B. Instruct the client to breathe deeply and cough frequently.
• C. Use a nasal cannula to deliver oxygen at a low flow rate.
• D. Encourage the client to remove the oxygen when eating or drinking.

Correct answer: C

Rationale: Using a nasal cannula to deliver oxygen at a low flow rate is the appropriate intervention for clients with COPD receiving oxygen therapy. High flow rates can lead to respiratory depression in COPD patients. This intervention helps maintain a safe and controlled oxygen delivery to prevent potential complications associated with high oxygen flow rates.

5. A 65-year-old woman presents with difficulty swallowing, weight loss, and a history of long-standing heartburn. She has been on proton-pump inhibitors for years, but her symptoms have worsened. What is the most likely diagnosis?

• A. Peptic stricture
• B. Esophageal cancer
• C. Achalasia
• D. Esophageal spasm

Correct answer: B

Rationale: The presentation of difficulty swallowing, weight loss, and worsening symptoms despite long-term use of proton-pump inhibitors raises suspicion for esophageal cancer, especially in a patient with a history of chronic heartburn. Esophageal cancer should be considered in this scenario due to the concerning symptoms and lack of improvement despite appropriate medical management.

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