Nursing Elites

1. The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?

• A. Ask another nurse to return with the medication when the client has hung up the phone
• B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
• C. Return the medication to the client's drawer on the cart and document that the client refused the dose
• D. Leave the medication with the client and let him take it when he finishes the conversation

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.

2. Rehabilitation after illness is classified under which level of healthcare?

• A. Primary
• B. Secondary
• C. Tertiary
• D. All three

Correct answer: C

Rationale: Rehabilitation after illness is classified as tertiary care. Tertiary care aims to help patients recover from illness, injuries, or disabilities, and restore their functionality. Primary care involves preventive measures and early disease detection, while secondary care focuses on diagnosis and treatment of specific conditions. Therefore, choices A, B, and D are incorrect as they do not specifically address the specialized nature of rehabilitation in healthcare.

3. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement?

• A. Stimulate the infant to cry
• B. Give oxygen by positive pressure
• C. Suction the oral and nasal passages
• D. Turn the infant onto the right side

Correct answer: C

Rationale: Suctioning the oral and nasal passages is the correct immediate intervention in this scenario. Regurgitation leading to cyanosis indicates a potential airway obstruction, which requires prompt action to clear. Stimulating the infant to cry (Choice A) may not address the underlying issue of airway obstruction. Giving oxygen by positive pressure (Choice B) can be beneficial, but clearing the airway obstruction takes precedence. Turning the infant onto the right side (Choice D) does not directly address the need to clear the airway.

4. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/hr. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?

• A. Daily weight
• B. Gastric residual volumes
• C. Bowel sounds
• D. Urinary and stool output

Correct answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.

5. What is the most common cause of acute pancreatitis?

• A. Gallstones
• B. Alcohol abuse
• C. Hypertriglyceridemia
• D. Infection

Correct answer: A

Rationale: The correct answer is A: Gallstones. Gallstones are the most common cause of acute pancreatitis as they obstruct the pancreatic duct, leading to inflammation. While alcohol abuse (Choice B) can also cause pancreatitis, gallstones are more prevalent. Hypertriglyceridemia (Choice C) is a less common cause of acute pancreatitis compared to gallstones. Infection (Choice D) is not a primary cause of acute pancreatitis; gallstones are the leading etiology.

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