Nursing Elites

1. An older adult client with eye dryness reports itching and excessive tearing. Which medication group is most likely to have produced this client's symptoms?

• A. Antiinfectives and antidepressants.
• B. Anticoagulants and antihistamines.
• C. Antiretrovirals and antivirals.
• D. Antihypertensives and anticholinergics.

Correct answer: D

Rationale: The correct answer is D: Antihypertensives and anticholinergics. Anticholinergics are known to cause dryness of secretions, including dry eyes, which can lead to symptoms of eye dryness, itching, and excessive tearing as reported by the client. Choices A, B, and C are incorrect as they do not typically cause the symptoms described by the client. Antiinfectives, antidepressants, anticoagulants, antihistamines, antiretrovirals, and antivirals do not commonly lead to dry eyes, itching, and excessive tearing.

2. An adolescent client with intellectual disability refuses oral hygiene. A behavior modification program is recommended. Which reinforcement is best for the nurse to implement?

• A. Candy for successful oral hygiene tasks.
• B. Tokens for each successful oral hygiene task.
• C. Privilege restrictions for refusing oral hygiene tasks.
• D. Preferred activities or privileges for compliance.

Correct answer: D

Rationale: In this scenario, the best reinforcement for the nurse to implement is preferred activities or privileges for compliance. Positive reinforcement with privileges is effective in encouraging behavior change in adolescents, including those with intellectual disabilities. Choice A (Candy for successful oral hygiene tasks) may not be suitable as it involves providing a sugary reward, which contradicts the goal of oral hygiene. Choice B (Tokens for each successful oral hygiene task) could be effective but may not be as motivating as preferred activities or privileges. Choice C (Privilege restrictions for refusing oral hygiene tasks) focuses on negative reinforcement, which is not as effective as positive reinforcement in behavior modification.

3. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Yogurt, milk, and pudding
• B. Tea, lentils, and potato soup
• C. Ice cream, broth, and fruit smoothies
• D. Orange juice, mashed potatoes, and soft cheese

Correct answer: A

Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.

4. The healthcare worker is wearing PPE while caring for a client. When exiting the room, which PPE should be removed first?

• A. Gloves
• B. Face shield
• C. Mask
• D. Gown

Correct answer: A

Rationale: Gloves should be removed first as they are most likely to be contaminated. This is followed by the gown, then face shield, and mask. Correct removal sequence helps prevent contamination. Removing gloves first reduces the risk of transferring pathogens from the gloves to other PPE or surfaces. Face shield and mask should be removed last as they protect mucous membranes from exposure to contaminants. Removing PPE in the correct sequence is crucial in preventing the spread of infections.

5. While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?

• A. Administer prescribed diuretics
• B. Prepare for intubation
• C. Notify the healthcare provider immediately
• D. Obtain sputum sample

Correct answer: D

Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics is essential in managing pulmonary edema but obtaining a sputum sample should take priority. Intubation may be necessary in severe cases but is not the initial intervention. Notifying the healthcare provider is important, but immediate action to diagnose and treat the condition is crucial.

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