Nursing Elites

1. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?

• A. Encourage the client to drink more slowly
• B. Stop feeding and assess for signs of aspiration
• C. Elevate the head of the bed further
• D. Teach coughing and deep breathing exercises

Correct answer: B

Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.

2. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information?

• A. His daughter's observations suggest the client is depressed
• B. His compulsiveness about food may indicate new cognitive decline
• C. Obsessiveness with food is common in diabetic clients
• D. If the client was compulsive about food when he was younger, the aging process can magnify this

Correct answer: D

Rationale: Age can magnify pre-existing compulsive tendencies. If the client was detail-oriented about food earlier in life, this behavior may intensify with aging. It's important to acknowledge and address the client's concerns respectfully. Choices A, B, and C are incorrect because the daughter's observations do not necessarily point to depression, the compulsiveness about food does not indicate new cognitive decline without further assessment, and obsessiveness with food is not specifically common in diabetic clients.

3. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?

• A. Administer furosemide as prescribed.
• B. Administer albumin to increase oncotic pressure.
• C. Elevate the client's legs to reduce swelling.
• D. Administer a sodium-restricted diet.

Correct answer: A

Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.

4. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

5. After repositioning an immobile client, the nurse observes an area of hyperemia. What action should the nurse take to assess for blanching?

• A. Document the presence in the client’s record.
• B. Apply light pressure over the area.
• C. Apply heat to the area and reassess in 30 minutes.
• D. Apply cold compresses to reduce the redness.

Correct answer: B

Rationale: The correct action for the nurse to take to assess for blanching in an area of hyperemia is to apply light pressure over the area. Blanching is the temporary whitening of the skin when pressure is applied and then released, indicating that the blood flow is returning to the area. Applying light pressure helps in determining if the hyperemic area blanches, ensuring that blood flow is adequate. Choices A, C, and D are incorrect because documenting findings, applying heat, or using cold compresses are not appropriate actions for assessing blanching in an area of hyperemia.

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