Nursing Elites

1. The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?

• A. Turn and reposition immobile patients at least every 2 hours.
• B. Place patients with altered consciousness in side-lying positions.
• C. Monitor for respiratory symptoms in immunosuppressed patients.
• D. Insert nasogastric tube for feedings in patients with swallowing problems.

Correct answer: B

Rationale: To prevent aspiration in a high-risk patient, the most effective nursing action is to place patients with altered consciousness in side-lying positions. This position helps decrease the risk of aspiration as it prevents pooling of secretions and facilitates drainage. Turning and repositioning immobile patients every 2 hours is essential for preventing pressure ulcers and improving circulation but does not directly address the risk of aspiration. Monitoring respiratory symptoms in immunosuppressed patients is crucial to detect pneumonia early, but it does not directly prevent aspiration. Inserting a nasogastric tube for feedings in patients with swallowing problems may be necessary for nutritional support but does not address the risk of aspiration directly. Patients at high risk for aspiration include those with altered consciousness, difficulty swallowing, and those with nasogastric intubation, among others. Placing patients with altered consciousness in a side-lying position is a key intervention to reduce the risk of aspiration in this population. Other high-risk groups for aspiration include those who are seriously ill, have poor dentition, or are on acid-reducing medications.

2. The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report

• A. Loss of consciousness
• B. Feeding problems
• C. Poor weight gain
• D. Fatigue with crying

Correct answer: A

Rationale: The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.

3. Which of the following can cause coup-contrecoup injuries?

• A. Rotational forces
• B. Deformation forces
• C. Deceleration forces
• D. Acceleration forces

Correct answer: C

Rationale: Deceleration forces occur when the head is moving and abruptly comes to a stop, such as in a car crash. This sudden deceleration can cause the brain to hit against the skull, resulting in coup-contrecoup injuries. In a coup-contrecoup injury, the brain is damaged on opposite sides due to the initial impact and the rebound effect inside the skull. Rotational forces usually result in diffuse axonal injuries rather than coup-contrecoup injuries. Deformation forces can cause focal brain injuries but not coup-contrecoup injuries. Acceleration forces typically lead to diffuse brain injuries, not coup-contrecoup injuries. Therefore, the correct answer is deceleration forces.

4. Which of the following glands found in the skin secretes a liquid called Sebum?

• A. Apocrine Glands
• B. Sebaceous Glands
• C. Lacrimal Glands
• D. Sweat Glands

Correct answer: B

Rationale: Sebum is a liquid secreted by glands in the skin known as sebaceous glands. Sebum's primary function is to lubricate the skin and help maintain its integrity. Apocrine glands secrete a different type of sweat that is odorless but can develop an odor when combined with bacteria on the skin. Lacrimal glands produce tears to keep the eyes moist, and sweat glands secrete sweat to regulate body temperature through evaporation. Therefore, the correct answer is Sebaceous Glands because they specifically secrete sebum, distinguishing them from the other gland types mentioned.

5. A patient with severe Gastroesophageal Reflux Disease is receiving discharge teaching. Which of these statements by the patient indicates a need for more teaching?

• A. ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.''
• B. ''I'm going to make sure to remain upright after meals and elevate my head when I sleep.''
• C. ''I won't be drinking tea or coffee or eating chocolate anymore.''
• D. ''I'm going to start trying to lose some weight.''

Correct answer: A

Rationale: The correct answer is ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.'' This statement indicates a need for more teaching because large meals increase the volume and pressure in the stomach, delaying gastric emptying, and worsening symptoms of Gastroesophageal Reflux Disease (GERD). The recommended approach is to eat smaller, more frequent meals (4-6 small meals a day) to reduce acid reflux. Choices B, C, and D demonstrate good understanding of GERD management by highlighting the importance of staying upright after meals, avoiding trigger foods like tea, coffee, and chocolate, and addressing weight management, which are all appropriate strategies to manage GERD symptoms.

Similar Questions