Nursing Elites

1. A patient with stomatitis is receiving oral care education from a nurse. Which instructions will the nurse provide?

• A. Avoid commercial mouthwashes.
• B. Avoid normal saline rinses.
• C. Brush with a hard toothbrush.
• D. Brush with an alcohol-based toothpaste.

Correct answer: A

Rationale: The correct instruction for a patient with stomatitis is to avoid commercial mouthwashes. Commercial mouthwashes often contain alcohol and other ingredients that can irritate the already inflamed oral mucosa in patients with stomatitis. Avoiding commercial mouthwashes helps prevent further irritation and discomfort. Choice B is incorrect because normal saline rinses are gentle and can help soothe the oral mucosa in patients with stomatitis. Choice C is incorrect because a soft toothbrush should be used to prevent further irritation or injury to the gums. Choice D is incorrect because an alcohol-based toothpaste can be too harsh and drying for patients with stomatitis.

2. The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?

• A. After the acute phase of the disease has passed.
• B. As soon as the ability to move is lost.
• C. Once the patient enters the rehab unit.
• D. When the patient requests it.

Correct answer: B

Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.

3. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

• A. Clean sutures along the incision site.
• B. Grasp the knot of the sutures with forceps.
• C. Cut the sutures close to the skin on one side.
• D. Pull out the sutures with forceps in one piece.

Correct answer: A

Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.

4. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Post-operatively, the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

• A. Notify the healthcare provider
• B. Administer the PRN dose of Albuterol
• C. Apply oxygen at 2 liters per nasal cannula
• D. Repeat the peak flow reading in 30 minutes

Correct answer: B

Rationale: In a client with moderate persistent asthma experiencing a drop in peak flow and chest tightness post-operatively, the first action the nurse should take is to administer the PRN dose of Albuterol. Albuterol is a short-acting bronchodilator that helps relieve bronchospasm and improve breathing. Notifying the healthcare provider (choice A) can be done after initiating immediate treatment with Albuterol. Applying oxygen (choice C) may be necessary but addressing the bronchospasm with Albuterol is the priority. Repeating the peak flow reading (choice D) can be considered after administering Albuterol to assess the response to treatment.

5. A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?

• A. Erythema on pressure points
• B. Lower-extremity pulse strength of 2+
• C. Fluid intake of 3,000 mL per day
• D. A bowel movement every other day

Correct answer: A

Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.

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