Nursing Elites

1. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

• A. Assist with personal care, but leave oral care for the nurse to complete.
• B. Provide a soft bristle brush for the client to use during oral care.
• C. Use alcohol-based mouthwash to clean the ulcers.
• D. Apply an antifungal cream to the mouth ulcers.

Correct answer: B

Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.

2. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)

• A. Monitor electrolyte levels.
• B. Maintain pulse oximetry.
• C. Provide assistance with mobility.
• D. All of the Above

Correct answer: D

Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.

3. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client’s admitting diagnosis?

• A. Jugular vein distention.
• B. Crackles in the lung bases.
• C. Peripheral edema.
• D. Bounding peripheral pulses.

Correct answer: B

Rationale: The correct answer is B: Crackles in the lung bases. Crackles in the lung bases are indicative of pulmonary congestion, which is a classic sign of left-sided heart failure. Left-sided heart failure leads to a backup of blood into the lungs, causing fluid leakage into the alveoli and resulting in crackles upon auscultation. Choices A, C, and D are less specific to left-sided heart failure. Jugular vein distention can be seen in right-sided heart failure, peripheral edema can be seen in both right and left-sided heart failure, and bounding peripheral pulses are more indicative of conditions like hyperthyroidism or anemia rather than specifically supporting left-sided heart failure.

4. A client with liver cirrhosis is at risk for developing hepatic encephalopathy. Which clinical manifestation should the nurse monitor for?

• A. Kussmaul respirations
• B. Asterixis (flapping tremor)
• C. Bradycardia
• D. Hypertension

Correct answer: B

Rationale: Corrected Rationale: Asterixis, also known as a flapping tremor, is a common sign of hepatic encephalopathy, indicating neurological dysfunction due to liver failure. Kussmaul respirations (option A) are associated with metabolic acidosis, which is not a typical manifestation of hepatic encephalopathy. Bradycardia (option C) and hypertension (option D) are not typically associated with hepatic encephalopathy; in fact, hepatic encephalopathy is more commonly associated with alterations in mental status, neuromuscular abnormalities, and changes in behavior.

5. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?

• A. Hypotension
• B. Tachycardia
• C. Severe headache
• D. Flushed skin below the level of injury

Correct answer: C

Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.

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