Nursing Elites

1. The nurse is providing discharge instructions to a client who has had a stroke. Which intervention should the nurse recommend to prevent aspiration during meals?

• A. Encourage the client to take large bites of food
• B. Advise the client to eat quickly to prevent fatigue
• C. Offer the client thin liquids with meals
• D. Instruct the client to sit upright while eating

Correct answer: D

Rationale: Instructing the client to sit upright while eating is crucial to prevent aspiration in stroke clients. This position helps in safe swallowing and reduces the risk of food or liquid entering the airway. Encouraging the client to take large bites of food (Choice A) can increase the risk of choking and aspiration. Advising the client to eat quickly (Choice B) may lead to fatigue and compromise safe swallowing. Offering thin liquids (Choice C) can also increase the risk of aspiration in stroke clients, as thicker liquids are usually recommended to prevent aspiration.

2. Which of these findings should the nurse report immediately after a client has a liver biopsy?

• A. Temperature of 99.5 degrees F (37.5 degrees C)
• B. Blood pressure of 108/70
• C. Pulse oximetry reading of 96%
• D. Severe abdominal pain

Correct answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

3. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

4. A client with anemia is prescribed iron supplements. What teaching should the nurse provide?

• A. Take iron supplements with meals to prevent stomach upset.
• B. Take iron supplements with milk to improve absorption.
• C. Expect black, tarry stools as a side effect of iron supplements.
• D. Take iron supplements with vitamin C to improve absorption.

Correct answer: D

Rationale: The correct answer is D: Take iron supplements with vitamin C to improve absorption. Vitamin C enhances iron uptake, making it more bioavailable for the body. It is essential to avoid taking iron supplements with milk (choice B) as calcium-rich foods can hinder iron absorption. Taking iron supplements with meals (choice A) can help reduce stomach upset, but the optimal way to enhance absorption is with vitamin C. Black, tarry stools (choice C) are not a typical side effect of iron supplements and should be reported to the healthcare provider.

5. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be

• A. Wrap the stump with an elastic bandage to prevent swelling
• B. Keep the skin on the stump clean and dry
• C. Use alcohol to cleanse the stump daily
• D. Apply moisturizing lotion to the stump daily

Correct answer: B

Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.

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