Nursing Elites

1. A client receiving chemotherapy for cancer has developed stomatitis. Which of the following interventions should the nurse implement?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct intervention for a client with stomatitis, a common side effect of chemotherapy, is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the mouth. Providing lemon-glycerin swabs (choice A) can be too harsh and irritating to the mouth. Avoiding toothpaste (choice C) is not necessary unless it contains harsh ingredients that can further irritate the mouth. Instructing the client to use a mouthwash containing alcohol (choice D) is contraindicated as alcohol-containing mouthwashes can be too harsh and drying for clients with stomatitis.

2. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?

• A. Nausea
• B. Confusion about own name
• C. Rapid pulse
• D. Vomiting

Correct answer: B

Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.

3. A healthcare provider is caring for a client who has a leg fracture and reports severe pain. Which of the following actions should the healthcare provider take first?

• A. Administer pain medication
• B. Reposition the client's leg
• C. Elevate the client's leg
• D. Check the client's neurovascular status

Correct answer: D

Rationale: Checking the client's neurovascular status is the priority when caring for a client with severe pain after a leg fracture. This assessment is crucial to identify any signs of vascular compromise or nerve damage, such as compartment syndrome. Administering pain medication can help alleviate the pain but should only be done after ensuring the client's neurovascular status is stable. Repositioning or elevating the leg may worsen the condition if there are underlying vascular issues, making these options lower in priority than assessing neurovascular status.

4. A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?

• A. History of gastrointestinal bleeding
• B. Prothrombin time of 12 seconds
• C. Platelet count of 180,000/mm³
• D. Creatinine level of 1.0 mg/dL

Correct answer: A

Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: D

Rationale: In a situation where a verbal prescription for restraints is obtained for a client experiencing acute mania, the nurse should document the client's condition every 15 minutes. This frequent documentation allows for accurate monitoring of the client's condition, ensuring safety and compliance. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is not directly related to the need for restraints in this scenario. Obtaining a prescription for restraint within 4 hours (Choice C) is not a priority when a verbal prescription is already obtained and immediate action is needed for the client's safety.

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