Nursing Elites

1. The nurse is preparing to administer an oral medication to a client with dysphagia. Which action should the nurse take?

• A. Crush the medication and mix it with applesauce.
• B. Have the client drink a full glass of water with the medication.
• C. Administer the medication with a small amount of pudding.
• D. Place the medication at the back of the client's tongue.

Correct answer: C

Rationale: The correct action for the nurse to take when administering oral medication to a client with dysphagia is to administer the medication with a small amount of pudding. This method helps prevent aspiration in clients with dysphagia by ensuring easier swallowing. Crushing the medication and mixing it with applesauce (Choice A) might alter the medication's efficacy. Having the client drink a full glass of water with the medication (Choice B) may not be suitable for a client with dysphagia as it can increase the risk of aspiration. Placing the medication at the back of the client's tongue (Choice D) can also lead to aspiration and is not recommended.

2. The instructor is teaching a prenatal class about the importance of folic acid. Which outcome indicates that the teaching was effective?

• A. participants can list foods high in folic acid
• B. participants plan to take folic acid supplements daily
• C. participants understand the risks of folic acid deficiency
• D. participants demonstrate how to read nutrition labels for folic acid content

Correct answer: B

Rationale: The correct answer is B because planning to take folic acid supplements daily is a proactive step towards preventing folic acid deficiency and reducing the risk of neural tube defects in pregnancy. While choice A is important for dietary knowledge, the direct action of taking supplements is more effective. Choice C, understanding the risks, is good but does not ensure action. Choice D, reading nutrition labels, is helpful but doesn't guarantee intake of folic acid.

3. The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning properly?

• A. Continuous bubbling in the water-seal chamber.
• B. No fluctuation (tidaling) in the water-seal chamber.
• C. Intermittent bubbling in the suction control chamber.
• D. Drainage of clear, pale yellow fluid from the chest tube.

Correct answer: D

Rationale: The drainage of clear, pale yellow fluid from the chest tube is an indication of proper chest tube functioning. Clear, pale yellow fluid signifies normal drainage from the pleural space without any signs of infection or complications. Choices A, B, and C are incorrect because continuous bubbling in the water-seal chamber, no fluctuation in the water-seal chamber, and intermittent bubbling in the suction control chamber are all indications of potential issues or malfunctioning of the chest tube system, which would require further assessment and intervention.

4. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which laboratory result requires immediate intervention?

• A. Amylase of 120 U/L.
• B. Lipase of 150 U/L.
• C. Calcium of 8.5 mg/dL.
• D. Blood glucose of 250 mg/dL.

Correct answer: D

Rationale: The correct answer is D, 'Blood glucose of 250 mg/dL.' In a client with acute pancreatitis, elevated blood glucose levels can indicate poor control of diabetes or stress response from the acute illness. Immediate intervention is necessary to prevent complications like worsening pancreatitis, infections, or other metabolic issues. Choices A and B, 'Amylase of 120 U/L' and 'Lipase of 150 U/L,' are commonly elevated in pancreatitis but do not require immediate intervention unless significantly elevated. Choice C, 'Calcium of 8.5 mg/dL,' is within the normal range and not a priority in this scenario.

5. A client with a history of alcoholism is admitted with pancreatitis. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Nausea and vomiting.
• B. Epigastric pain radiating to the back.
• C. Temperature of 102°F (38.9°C).
• D. Mild jaundice.

Correct answer: C

Rationale: A temperature of 102°F (38.9°C) is the most important assessment finding to report to the healthcare provider in a client with pancreatitis and a history of alcoholism. Fever in this context can indicate infection, which is a serious complication requiring immediate intervention. Nausea and vomiting (choice A) are common symptoms of pancreatitis but may not require immediate intervention unless severe. Epigastric pain radiating to the back (choice B) is a classic symptom of pancreatitis and should be addressed, but a fever takes precedence. Mild jaundice (choice D) may be present in pancreatitis but is not as urgent as a high temperature signaling possible infection.

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