Nursing Elites

1. After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first?

• A. Reorient the client to the room
• B. Place an eye patch on one eye
• C. Evaluate the client's ability to swallow
• D. Perform range of motion exercises

Correct answer: C

Rationale: Evaluating the client's ability to swallow is the priority intervention in this scenario. Pontine myelinolysis can affect neurological functions, including swallowing ability, putting the client at risk for aspiration. Assessing the client's ability to swallow will help prevent complications such as aspiration pneumonia. Reorienting the client to the room, placing an eye patch, or performing range of motion exercises are not as critical as ensuring the client can safely swallow.

2. A client with chronic obstructive pulmonary disease (COPD) presented with shortness of breath. Oxygen therapy was started at 2 liters/minute via nasal cannula. The arterial blood gases (ABGs) after treatment were pH 7.36, PaO2 52, PaCO2 59, HCO3 33. Which statement describes the most likely cause of the simultaneous increase in both PaO2 and PaCO2?

• A. The client is hyperventilating due to anxiety.
• B. The hypoxic drive was reduced by the oxygen therapy.
• C. The client is experiencing respiratory alkalosis.
• D. The client is experiencing metabolic acidosis.

Correct answer: B

Rationale: Oxygen therapy can reduce the hypoxic drive in COPD patients, leading to increased PaCO2 levels while improving oxygenation (PaO2). In this case, the increase in PaO2 and PaCO2 is due to the reduction of the hypoxic drive by the supplemental oxygen. Choice A is incorrect because hyperventilation would lead to decreased PaCO2. Choice C is incorrect as the ABG values do not indicate respiratory alkalosis. Choice D is incorrect as the ABG values do not support metabolic acidosis.

3. Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement?

• A. Remove all sources of liquids from the client's room
• B. Allow family to give the client a measured amount of ice chips
• C. Restrict family visiting until the client's condition is stable
• D. Provide the client with oral swabs to moisten his mouth

Correct answer: D

Rationale: In this scenario, the nurse should provide the client with oral swabs to moisten his mouth. This intervention helps alleviate the client's thirst without increasing fluid intake, which is essential in managing AKI. Removing all sources of liquids from the client's room (Choice A) may not address the underlying issue of thirst and could lead to increased frustration. Allowing the family to give the client ice chips (Choice B) would add to the client's fluid intake, contradicting the restriction. Restricting family visiting (Choice C) is not necessary and does not directly address the client's thirst.

4. A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?

• A. Encourage the client to eat quickly.
• B. Provide a straw for liquids.
• C. Place the client in an upright position during meals.
• D. Offer thin liquids.

Correct answer: C

Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.

5. The parents of a child who has had a myringotomy are instructed by the nurse to place the child in which position?

• A. Supine
• B. On the affected side
• C. On the unaffected side
• D. In Trendelenburg's position

Correct answer: B

Rationale: Placing the child on the affected side after a myringotomy facilitates ear drainage. This position helps prevent accumulation of fluids in the ear canal, aiding in the healing process. Placing the child in the supine position (Choice A) or on the unaffected side (Choice C) may not be as effective in promoting drainage. The Trendelenburg's position (Choice D) with the head lower than the body is used for conditions requiring increased venous return, not for post-myringotomy care.

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