Nursing Elites

1. 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.

2. The health care provider is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation?

• A. When the course of antibiotics is complete
• B. When a negative CNS culture is obtained
• C. When the antibiotics have been initiated for 24 hours
• D. When the child has no symptoms of the disease

Correct answer: C

Rationale: The correct answer is C because a child with bacterial meningitis should be isolated for at least 24 hours until antibiotic therapy has been initiated. This period allows the antibiotics to start working against the infection, reducing the risk of spreading it to others. Choice A is incorrect because isolation is not solely based on completing the course of antibiotics; the initiation is crucial. Choice B is incorrect as waiting for a negative CNS culture may take longer and delay necessary precautions. Choice D is incorrect as symptom resolution does not guarantee the eradication of the infection and may still pose a risk of transmission.

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. 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.

5. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)

• A. Verify pedal pulses using a doppler pulse device.
• B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
• C. Evaluate the application of the splint to the left leg.
• D.

Correct answer: C

Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.

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