Nursing Elites

1. A nurse is teaching a client who has out about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?

• A. Fruit juice
• B. Alcohol
• C. Milk
• D. Coffee

Correct answer: B

Rationale:

2. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?

• A. Deliver upward abdominal thrusts with a fisted hand
• B. Perform a blind finger sweep of the child's mouth
• C. Complete five rapid back blows between the shoulder blades
• D. Encourage the child to continue coughing

Correct answer: D

Rationale:

3. The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?

• A. Hyperthermia
• B. A cold environment
• C. Normal
• D. Hypothermia

Correct answer: A

Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

4. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

5. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?

• A. I will drink at least 3000 mL of water daily."?
• B. . 'I will shower every day in hot water."?
• C. I will avoid tights belts."?
• D. I will use a humidifier during the winter months."?

Correct answer: B

Rationale:

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