Nursing Elites

1. A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?

• A. Have the client lie down after meals
• B. Encourage the client to speak while eating
• C. Have the client sit upright for 1 hour following meals
• D. Offer thin liquids with meals

Correct answer: C

Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour following meals. This position facilitates swallowing and reduces the risk of aspiration. Choice A is incorrect because having the client lie down after meals can increase the risk of aspiration. Choice B is incorrect as talking while eating can lead to choking. Choice D is incorrect as thin liquids may be harder for a client with dysphagia to swallow safely.

2. A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?

• A. The possibility of pregnancy within 4 weeks
• B. Client allergy to strawberry
• C. Client history of genital herpes
• D. The possibility of overseas travel in the next month

Correct answer: A

Rationale: The correct answer is A. The MMR vaccine is contraindicated in pregnant women due to the risk of fetal harm. It is recommended that women avoid becoming pregnant for at least 4 weeks after receiving the vaccine. Choice B, client allergy to strawberry, is not a contraindication for the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication for the MMR vaccine.

3. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?

• A. Uterine fundus is firm and midline
• B. Client's perineal pad is saturated in 15 minutes
• C. Client reports breast tenderness when breastfeeding
• D. Client's temperature is 100.4°F

Correct answer: B

Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.

4. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?

• A. Keep a padded tongue depressor near the bedside
• B. Place a pillow under the client’s head while in bed during a seizure
• C. Administer diazepam intravenously at the onset of seizures
• D. Position the client on their side during a seizure

Correct answer: D

Rationale: Clients who have seizures are at risk for injury and aspiration. Therefore, the nurse should instruct the family to position the client on their side during a seizure to maintain a clear airway. Placing a padded tongue depressor near the bedside (Choice A) is not recommended, as it can lead to oral injury during a seizure. Placing a pillow under the client’s head (Choice B) can obstruct the airway and increase the risk of aspiration. Administering diazepam orally (Choice C) is not typically done by family members during a seizure; this is usually prescribed by healthcare providers for specific situations.

5. A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?

• A. Take the medication with food
• B. Take the medication at bedtime
• C. Stand up slowly to prevent dizziness
• D. Increase fluid intake

Correct answer: C

Rationale: Patients with chronic kidney disease are prone to orthostatic hypotension, which can cause dizziness. To prevent this, the nurse should instruct the patient to stand up slowly. Options A, B, and D do not directly address the issue of orthostatic hypotension and dizziness in this scenario.

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