Nursing Elites

1. The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?

• A. the client who most recently rang their call bell
• B. the client who has been waiting the longest for their call bell to be answered
• C. the client who is in the most pain
• D. the client who may have a risk for an airway obstruction

Correct answer: D

Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority. Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.

2. What is the most effective way to prevent skin breakdown?

• A. assistive devices
• B. repositioning
• C. topical medications
• D. avoiding tape and bandages

Correct answer: V

Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (Choice A) may be beneficial in some cases, they are not universally as effective as repositioning. Topical medications (Choice C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (Choice D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.

3. Which of the following foods can cause diarrhea when consumed by a client with an ileostomy?

• A. eggs
• B. coffee
• C. fish
• D. garlic

Correct answer: B

Rationale: The correct answer is coffee. Coffee can cause diarrhea in clients with an ileostomy due to its stimulating effect on the digestive system, leading to increased bowel movements. Eggs, fish, and garlic are less likely to cause diarrhea in individuals with an ileostomy. However, they may contribute to odor due to the way they are digested and broken down in the body, affecting the smell of stool output but not necessarily causing diarrhea.

4. A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for:

• A. solutions administered in obstetrics.
• B. dilute antibiotics.
• C. large volumes of IV solutions.
• D. the neonatal and pediatric populations.

Correct answer: D

Rationale: The correct answer is 'the neonatal and pediatric populations.' Syringe pumps are commonly used in neonatal and pediatric populations because they allow for precise infusion of small volumes of medications or fluids at controlled rates. This is crucial for ensuring safety and accuracy in these delicate populations. Choice A is incorrect because syringe pumps are not limited to obstetrics; they are used in various healthcare settings. Choices B and C are incorrect because syringe pumps are not typically used for dilute antibiotics or large volumes of IV solutions. Instead, they are preferred for delivering small volumes accurately, making them ideal for neonatal and pediatric care.

5. Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?

• A. "I should provide a regular schedule for toileting."?
• B. "I should talk to my father less because he can't communicate."?
• C. "I should give my father oral care after every meal and bedtime."?
• D. "I should assist my father with eating and drinking."?

Correct answer: B

Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual. Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.

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