Nursing Elites

1. When admitting a client with fever, confusion, and decreased level of consciousness, what should the nurse do first after obtaining the client's history and assessment?

• A. Identify the client's needs
• B. Start intravenous fluids
• C. Notify the provider
• D. Conduct a neurological assessment

Correct answer: A

Rationale: When a client presents with fever, confusion, and decreased level of consciousness, the first step should be to identify the client's needs. This involves recognizing any immediate concerns or issues that require urgent attention. Starting intravenous fluids, notifying the provider, or conducting a neurological assessment may be necessary actions but should come after identifying the client's needs to ensure proper prioritization of care.

2. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to ambulate frequently.
• B. Apply warm, moist compresses to the affected leg.
• C. Massage the affected leg.
• D. Place the client in a supine position.

Correct answer: B

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.

3. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding?

• A. Beef broth
• B. Oatmeal
• C. Apple juice
• D. Toast

Correct answer: B

Rationale: Oatmeal is a soft, easy-to-swallow food, making it appropriate for clients with dysphagia, as it minimizes the risk of aspiration compared to liquids or hard foods. Beef broth (Choice A) is a liquid and may pose a risk of aspiration. Apple juice (Choice C) is a liquid and can also be a choking hazard for individuals with dysphagia. Toast (Choice D) is a hard food that may be difficult for a client with dysphagia to swallow safely.

4. A nurse is providing education on the use of aspirin. Which of the following should be included?

• A. It can increase the risk of bleeding
• B. It is safe to give to children
• C. It should be taken on an empty stomach
• D. It has no side effects

Correct answer: A

Rationale: The correct answer is A: 'It can increase the risk of bleeding.' Aspirin is known to have antiplatelet effects and can increase the risk of bleeding, especially if taken in high doses or for prolonged periods. Choice B is incorrect because aspirin is not safe for children due to the risk of Reye's syndrome. Choice C is incorrect because aspirin should be taken with food to minimize gastrointestinal side effects. Choice D is incorrect because aspirin, like any medication, can have side effects, such as gastrointestinal bleeding, ulcers, or allergic reactions.

5. A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?

• A. Inhale the medication deeply for 3-5 seconds
• B. Exhale forcefully before inhaling
• C. Shake the MDI vigorously before use
• D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth

Correct answer: A

Rationale: Corrected Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs. Choice A is the correct instruction for the use of a metered-dose inhaler (MDI). Choice B, exhaling forcefully before inhaling, is incorrect as it can lead to decreased medication delivery. Choice C, shaking the MDI vigorously before use, is also incorrect as excessive shaking can cause the medication to clump. Choice D, holding the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth, is not recommended as it may lead to improper inhalation technique.

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