Nursing Elites

1. The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?

• A. Wheezing
• B. Shortness of breath
• C. Use of accessory muscles
• D. Cough with sputum production

Correct answer: C

Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.

2. A patient with stomatitis is receiving oral care education from a nurse. Which instructions will the nurse provide?

• A. Avoid commercial mouthwashes.
• B. Avoid normal saline rinses.
• C. Brush with a hard toothbrush.
• D. Brush with an alcohol-based toothpaste.

Correct answer: A

Rationale: The correct instruction for a patient with stomatitis is to avoid commercial mouthwashes. Commercial mouthwashes often contain alcohol and other ingredients that can irritate the already inflamed oral mucosa in patients with stomatitis. Avoiding commercial mouthwashes helps prevent further irritation and discomfort. Choice B is incorrect because normal saline rinses are gentle and can help soothe the oral mucosa in patients with stomatitis. Choice C is incorrect because a soft toothbrush should be used to prevent further irritation or injury to the gums. Choice D is incorrect because an alcohol-based toothpaste can be too harsh and drying for patients with stomatitis.

3. A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?

• A. Report ABG results to the provider
• B. Instruct a client about how to use an incentive spirometer
• C. Administer an enteral feeding to a client who has an established gastrostomy tube
• D. Monitor the color of a client’s urinary output

Correct answer: D

Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.

4. A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?

• A. Keep the client's bed in the lowest position.
• B. Encourage the client to wear non-slip socks.
• C. Place a fall risk sign on the client's door.
• D. Use a gait belt when ambulating the client.

Correct answer: A

Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.

5. A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the nurse monitor for in this client?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Bradycardia

Correct answer: D

Rationale: The correct answer is D: Bradycardia. Beta-blockers are known to decrease heart rate, which can lead to bradycardia. This is a common side effect that nurses should monitor for in clients taking beta-blockers. Choices A, B, and C are incorrect because increased appetite, dry mouth, nausea, and vomiting are not typical side effects associated with beta-blockers. Therefore, the nurse should focus on monitoring for bradycardia in this client.

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