Nursing Elites

1. The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?

• A. Using waxed floss helps prevent bleeding
• B. Flossing removes plaque and tartar from the teeth
• C. Flossing at least 3 times a day is beneficial
• D. Applying toothpaste before flossing is harmful

Correct answer: B

Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.

2. A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included:

• A. Cotton balls
• B. Sterile gloves
• C. A suction catheter
• D. Tracheostomy tubes

Correct answer: A

Rationale: The correct answer is A: Cotton balls. Cotton balls are not suitable for tracheostomy care due to the risk of lint and contamination. When performing tracheostomy care, sterile supplies such as sterile gloves, a suction catheter, and tracheostomy tubes are essential. Sterile gloves are needed to maintain asepsis, a suction catheter is necessary for airway clearance, and tracheostomy tubes are crucial for maintaining a patent airway. Cotton balls should be avoided to prevent introducing lint or fibers into the tracheostomy site, which can lead to infection or airway obstruction.

3. A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?

• A. Musculoskeletal weakness
• B. Loss of appetite
• C. Increased heart rate during physical activity
• D. Left lower extremity tenderness

Correct answer: D

Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.

4. A nurse in a provider’s office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains?

• A. Cognitive
• B. Affective
• C. Psychomotor
• D. Kinesthetic

Correct answer: B

Rationale: The correct answer is B: Affective. The caregiver’s decision to postpone toilet training indicates a change in feelings or attitudes, which falls under the affective domain of learning. The affective domain relates to emotions, values, and attitudes. In this scenario, the caregiver's willingness to delay toilet training due to new information reflects a shift in attitude impacted by the educational session provided by the nurse. Choices A, C, and D are incorrect. The cognitive (choice A) domain involves intellectual skills and knowledge, the psychomotor (choice C) domain involves physical skills, and kinesthetic (choice D) is often used interchangeably with the psychomotor domain, which focuses on physical movement and coordination.

5. A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?

• A. Heart rate of 52 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Blood glucose level of 180 mg/dL
• D. Potassium level of 4.0 mEq/L

Correct answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

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