Nursing Elites

1. A nurse is caring for a client who has experienced a stroke and has aphasia. Which of the following communication strategies should the nurse use?

• A. Speak louder to help the client understand
• B. Speak using simple sentences and gestures
• C. Use a picture board to facilitate communication
• D. Have the client practice writing words down

Correct answer: C

Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.

2. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent constipation, straining, and subsequent bleeding, which is crucial for clients with thrombocytopenia. Encouraging the client to floss daily (Choice A) is important for oral hygiene but not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems to reduce the risk of foodborne illnesses but is not directly related to thrombocytopenia management.

3. A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?

• A. Ask another nurse to witness the disposal of the new patch
• B. Dispose of the patch in a sharps container
• C. Send the patch back to the pharmacy
• D. Document the refusal and remove the patch

Correct answer: A

Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.

4. What is the first intervention when a patient has difficulty breathing post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the initial intervention for a patient experiencing breathing difficulties post-surgery. Providing oxygen helps improve oxygenation and alleviate respiratory distress. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in addressing hypoxia and respiratory compromise.

5. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?

• A. Your baby needs an IV because she is not producing any tears
• B. Your baby needs an IV because her fontanels are bulging
• C. Your baby needs an IV because she is breathing slower than normal
• D. Your baby needs an IV because her heart rate is decreasing

Correct answer: A

Rationale: The correct answer is A. A lack of tear production is a sign of severe dehydration in infants, indicating the need for IV therapy. Option B, bulging fontanels, is a sign of increased intracranial pressure, not dehydration. Option C, breathing slower than normal, and Option D, decreasing heart rate, are not specific signs of severe dehydration that would indicate the need for IV therapy in this case.

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