Nursing Elites

1. Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?

• A. Urinary incontinence
• B. Constipation
• C. Nystagmus
• D. Occult bleeding

Correct answer: D

Rationale: The correct answer is D: Occult bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are known to cause gastrointestinal side effects, including occult bleeding. Occult bleeding refers to bleeding in the gastrointestinal tract that may not be visible in the stool, leading to potential complications like anemia. Urinary incontinence (choice A) is not a common side effect of NSAIDs. Constipation (choice B) is also not a typical side effect associated with NSAIDs. Nystagmus (choice C) is an involuntary eye movement and is not a common side effect of NSAIDs. Therefore, the nurse should caution clients about the risk of occult bleeding when using NSAIDs for arthritis pain management.

2. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain a sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw the catheter in a circular motion

Correct answer: A

Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.

3. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?

• A. Auscultation of breath sounds
• B. Measurement of peak expiratory flow
• C. Observation of the client's use of accessory muscles
• D. Assessment of the client's skin color

Correct answer: A

Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.

4. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?

• A. The treatment requires reapplication in 8 to 10 days.
• B. Bedding and clothing can be boiled or steamed.
• C. Children are not to share hats, scarves, and combs.
• D. Nit combs are necessary to comb out nits.

Correct answer: C

Rationale: The most crucial information to prevent the spread of lice in schools is to avoid sharing hats, scarves, and combs. This is important as lice can easily spread through shared personal items. Choices A, B, and D are not as critical as choice C in preventing the spread of lice. Reapplication of treatment, boiling or steaming bedding and clothing, and using nit combs are important but not as crucial as avoiding the sharing of personal items.

5. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is crucial in this situation as coughing while consuming liquids can indicate a risk of aspiration. Assessing the gag reflex can help determine if the client is safe to swallow without inhaling fluids into the lungs, which could lead to further respiratory complications. Adding a thickening agent may not address the underlying issue of aspiration risk. Feeding the client only solid foods is not appropriate without assessing the swallowing safety first. Increasing the rate of intravenous fluids does not directly address the client's difficulty with liquid intake.

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