Nursing Elites

1. A healthcare provider is receiving a prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the healthcare provider clarify?

• A. Dietitian consult
• B. Speech therapy referral
• C. Oral suction at the bedside
• D. Clear liquids

Correct answer: D

Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at high risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids. Therefore, the healthcare provider should clarify the prescription for clear liquids and consider recommending thickened liquids instead to reduce the risk of aspiration. Choice A, 'Dietitian consult,' is essential to ensure the client receives appropriate nutrition tailored to their condition. Choice B, 'Speech therapy referral,' is crucial for dysphagia management and rehabilitation. Choice C, 'Oral suction at the bedside,' is a standard intervention to maintain airway patency and is not contraindicated in clients with dysphagia.

2. A client with diabetes mellitus is learning to self-administer insulin. Which action by the client indicates the need for further teaching?

• A. The client rotates injection sites on the abdomen.
• B. The client draws up the insulin dose after warming the vial to room temperature.
• C. The client pinches the skin before injecting the insulin.
• D. The client injects the insulin at a 90-degree angle.

Correct answer: B

Rationale: Drawing up insulin after warming the vial to room temperature indicates a need for further teaching, as insulin should be at room temperature for administration. Choice A is correct as rotating injection sites helps prevent lipodystrophy. Choice C is correct as pinching the skin helps ensure proper subcutaneous injection. Choice D is correct as injecting insulin at a 90-degree angle is the recommended technique for subcutaneous injections.

3. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.

4. When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain radiate to other areas?
• C. Does the pain increase with movement?
• D. Can you rate your pain on a scale of 1 to 10?

Correct answer: A

Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.

5. When caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, experiencing peripheral neuropathy and urinary incontinence, on which areas does the nurse focus care?

• A. Decreased pain sensation and increased risk of skin impairment
• B. Decreased caloric intake and accelerated wound healing
• C. High risk for skin infection and low saliva pH level
• D. High risk for impaired venous return and dementia

Correct answer: A

Rationale: The nurse should focus on decreased pain sensation and increased risk of skin impairment due to the patient's conditions. Peripheral neuropathy can lead to decreased pain sensation, making the patient more prone to injuries without realizing it. Additionally, the combination of circulatory insufficiency, peripheral neuropathy, and urinary incontinence can increase the risk of skin breakdown and impaired healing. Choices B, C, and D are incorrect because they do not address the specific issues related to the patient's diagnoses and symptoms.

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