Nursing Elites

1. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

• A. Keeping the head of the bed elevated at 30 degrees
• B. Positioning the client in the prone position
• C. Placing the client in a lateral recumbent position
• D. Elevating the client's legs

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

2. Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who

• A. is immobile on prescribed bedrest.
• B. has pressure ulcers on several toes.
• C. has diminished pedal pulse volume.
• D. is confused and trying to climb out of bed.

Correct answer: A

Rationale: The correct answer is A. Pneumatic compression devices are most beneficial for immobile clients on prescribed bedrest to prevent deep vein thrombosis. Applying these devices helps in promoting circulation and preventing blood clots. Choices B, C, and D do not specifically relate to the primary indication for pneumatic compression devices, making them incorrect. Pressure ulcers, diminished pedal pulse volume, and confusion with climbing out of bed may require different interventions or treatments.

3. Which membrane lines the abdominal cavity?

• A. Perineum
• B. Pericardium
• C. Pleura
• D. Peritoneum

Correct answer: D

Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.

4. The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT levels
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.

5. A client with a history of stroke presents with dysphagia. What is the most important nursing intervention to prevent aspiration?

• A. Encourage the client to drink water between meals
• B. Position the client in a high-Fowler's position during meals
• C. Provide the client with thickened liquids
• D. Allow the client to eat quickly

Correct answer: B

Rationale: The correct answer is B: Position the client in a high-Fowler's position during meals. Placing the client in a high-Fowler's position (sitting upright at a 90-degree angle) helps reduce the risk of aspiration by ensuring that the airway is protected during swallowing. This position facilitates easier swallowing and decreases the likelihood of food or liquids entering the respiratory tract. Encouraging the client to drink water between meals (choice A) does not directly address the risk of aspiration during meals. Providing thickened liquids (choice C) may be necessary for some patients with dysphagia but is not the most important intervention to prevent aspiration. Allowing the client to eat quickly (choice D) without proper positioning and precautions can increase the risk of aspiration.

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