Nursing Elites

1. When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?

• A. Psychologist
• B. Social worker
• C. Occupational therapist
• D. Speech-language pathologist

Correct answer: D

Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.

2. A healthcare professional in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the healthcare professional take first?

• A. Obtain a baseline ECG.
• B. Obtain a blood specimen for ABG analysis.
• C. Insert an 18-gauge IV catheter.
• D. Administer 100% humidified oxygen.

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, airway compromise is a critical concern. Administering 100% humidified oxygen is the priority to ensure adequate oxygenation. This intervention takes precedence over obtaining baseline ECG, obtaining blood specimens, or inserting an IV catheter, as airway management and oxygenation are fundamental in the initial assessment and management of a client with potential airway compromise.

3. Which of the following is included in Orem’s theory?

• A. Maintenance of a sufficient intake of air
• B. Self-perception
• C. Love and belonging
• D. Physiological needs

Correct answer: A

Rationale: Orem's theory, also known as the Self-Care Deficit Nursing Theory, focuses on individuals' ability to perform self-care to maintain health and well-being. One specific component of this theory is the maintenance of a sufficient intake of air, which is crucial for sustaining life and overall health. Option A is the correct choice as it directly relates to meeting physiological needs, such as the intake of air, to support optimal functioning and health. Choices B, C, and D are incorrect as they do not specifically align with Orem's emphasis on self-care and meeting physiological requirements.

4. The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

• A. Oral
• B. Axillary
• C. Radial
• D. Heat-sensitive tape

Correct answer: A

Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely. Axillary temperature may be affected by environmental factors, while radial temperature measurement is not a standard method for assessing core body temperature. Heat-sensitive tape is not a recognized method for assessing body temperature in clinical practice.

5. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Allow extra time for the client to perform tasks

Correct answer: C

Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.

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