Nursing Elites

1. A client has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

• A. Providing a straw for consumption of liquids
• B. Encouraging larger bites
• C. Placing the client in semi-Fowler's position during meals
• D. Instructing the client to tilt head forward when swallowing

Correct answer: C

Rationale: Placing the client in semi-Fowler's position during meals is the correct intervention for a client with acute dysphagia. This position helps prevent aspiration by facilitating swallowing. Providing a straw for consumption of liquids (Choice A) can increase the risk of aspiration and is not recommended for clients with dysphagia. Encouraging larger bites (Choice B) can also increase the risk of choking and aspiration. Instructing the client to tilt the head forward when swallowing (Choice D) is not the recommended technique for managing dysphagia as it does not address the underlying issue effectively.

2. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?

• A. Sensation of taste
• B. Sensation of pressure
• C. Sensation of smell
• D. Urge to defecate

Correct answer: B

Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.

3. If a person could not make bile, what would happen?

• A. experience fatigue, as the body would not be able to make lipid carriers to deliver fat to body cells for energy
• B. have less cholesterol being made by the liver
• C. need to consume higher levels of fat
• D. be unable to absorb most lipids, and fat would be excreted in the feces

Correct answer: D

Rationale: The correct answer is D. Bile is essential for emulsifying fats in the small intestine, allowing them to be absorbed. Without bile, most fats would not be absorbed and would be excreted in the feces. Choices A, B, and C are incorrect because the primary role of bile is in the digestion and absorption of fats, rather than affecting lipid carriers, cholesterol production, or dietary fat consumption.

4. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

5. Mang Caloy is scheduled to have a hemorrhoidectomy, after the operation, you would expect that the client’s position post operatively will be:

• A. Knee chest position
• B. Side lying position
• C. Sims position
• D. Genopectoral position

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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