Nursing Elites

1. A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?

• A. I will monitor my husband for coughing while he is eating
• B. I will monitor my husband for pocketing food in his mouth
• C. I will monitor for a change in my husband's voice after he swallows
• D. I will monitor my husband for tilting his head forward when he swallows

Correct answer: D

Rationale: The correct answer is D. Tilting the head forward during swallowing is not a compensatory technique for dysphagia and may increase the risk of aspiration. Choices A, B, and C are correct statements indicating appropriate monitoring for manifestations of dysphagia: coughing while eating, pocketing food in the mouth, and changes in voice after swallowing are all signs that should be monitored.

2. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?

• A. Place the call light within the patient's reach.
• B. Apply a yellow fall risk bracelet to the patient.
• C. Assist the patient when ambulating.
• D. Ensure the patient's room is well-lit.

Correct answer: B

Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.

3. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?

• A. Do not change the mask if the nurse is comfortable.
• B. Change the mask when relieved by the next shift.
• C. Apply a new mask.
• D. Reapply the mask after it air-dries.

Correct answer: C

Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.

4. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

• A. Monitor the patient's blood pressure regularly.
• B. Change the CVC dressing every 72 hours.
• C. Flush the CVC with normal saline every shift.
• D. Avoid using the CVC for blood draws.

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

5. While reviewing notes from a previous shift, a nurse finds incomplete documentation. What is the most appropriate action?

• A. Complete the missing documentation
• B. Notify the nurse manager of the issue
• C. Ask the nurse to complete the documentation
• D. Confront the nurse about the incomplete notes

Correct answer: B

Rationale: The most appropriate action when finding incomplete documentation is to notify the nurse manager of the issue. This ensures that accurate records are maintained and the situation can be addressed properly. Completing the missing documentation on behalf of someone else may lead to inaccuracies, asking the nurse to complete it may not guarantee timely correction, and confronting the nurse could create a confrontational situation that is not conducive to effective teamwork.

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