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. In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. Intact skin with non-blanchable redness.
• C. Full-thickness tissue loss with visible fat.
• D. Full-thickness tissue loss with exposed bone, tendon, or muscle.

Correct answer: A

Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.

3. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?

• A. Administer a prescribed sedative
• B. Encourage client to drink water
• C. Apply a high flow venturi mask
• D. Assist her to an upright position

Correct answer: D

Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.

4. During the admission interview, an older client answers some questions inappropriately. The nurse notes that a hearing aid is in one ear. Which intervention is most helpful in assisting the client to hear the nurse’s question?

• A. Move to the client's other side.
• B. Speak louder into the client's ear with the hearing aid.
• C. Ask the client to adjust the hearing aid volume.
• D. Restate questions articulating consonants carefully.

Correct answer: D

Rationale: Restating questions with clear articulation is the most helpful intervention in assisting the client to hear the nurse's question. This approach ensures that the client can better understand the question, especially if there are issues with the hearing aid. Moving to the client's other side or speaking louder into the ear with the hearing aid may not effectively address the problem of clarity in communication. Asking the client to adjust the hearing aid volume assumes that the issue lies solely with the volume, while restating questions with clear articulation can help overcome various hearing difficulties.

5. After a CT scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?

• A. Call respiratory therapy to administer a breathing treatment.
• B. Send for an emergency tracheostomy set.
• C. Prepare a dose of epinephrine.
• D. Review the client's complete list of allergies.

Correct answer: C

Rationale: Preparing a dose of epinephrine is the correct intervention in this situation as the client is displaying symptoms of an anaphylactic reaction to the contrast medium used during the CT scan. Epinephrine is the first-line treatment for anaphylaxis due to its ability to reverse the symptoms rapidly. Calling respiratory therapy for a breathing treatment (Choice A) may not address the underlying allergic reaction and delay appropriate treatment. Sending for an emergency tracheostomy set (Choice B) is not indicated as the client's symptoms suggest an allergic reaction rather than airway obstruction. Reviewing the client's complete list of allergies (Choice D) is important but would not provide immediate relief for the client's current symptoms; administering epinephrine takes precedence in this situation.

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