Nursing Elites

1. What is the function of the epiglottis during swallowing?

• A. Prevents food from entering the trachea
• B. Aids in food propulsion
• C. Enhances taste sensation
• D. Lubricates the esophagus

Correct answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

2. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

• A. Avoid crossing your legs at the knees or ankles.
• B. Do not sleep on the side of the hip that was operated on.
• C. Sit in high chairs and keep your knees higher than your hips.
• D. Do not bend forward at the waist to pick up objects.

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

3. An adult client is undergoing weekly external radiation treatments for breast cancer and reports increasing fatigue. What action should the nurse take?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: The correct action for the nurse to take when a client undergoing radiation treatment for breast cancer reports increasing fatigue is to reinforce the need for extra rest periods and plenty of sleep. Fatigue is a common side effect of radiation therapy, and adequate rest and sleep can help manage this symptom. Notifying the healthcare provider or charge nurse immediately (choice A) is not necessary for increasing fatigue, as it is expected during radiation therapy. Offering to reschedule the treatment for the following week (choice B) is not the best initial action for managing fatigue. Planning to monitor the client's vital signs every 30 minutes (choice C) is unnecessary and not directly related to managing fatigue caused by radiation therapy.

4. An older postoperative client has the nursing diagnosis 'impaired mobility related to fear of falling.' Which desired outcome best directs the PN's actions for the client?

• A. The client will ambulate with assistance every 4 hours
• B. The physical therapist will instruct the client in the use of a walker
• C. The client will use self-affirmation statements to decrease fear
• D. The PN will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: The correct answer is C. Using self-affirmation statements helps the client reduce fear and regain confidence in mobility, which is essential for improving impaired mobility. Choice A focuses more on the frequency of ambulation rather than addressing the fear of falling. Choice B involves the physical therapist and the use of a walker, which may not directly address the client's fear. Choice D is a safety measure but does not specifically target the client's fear of falling.

5. What is the most appropriate nursing action when a patient on anticoagulant therapy develops sudden, severe back pain?

• A. Administer pain medication
• B. Apply a cold compress to the back
• C. Assess for signs of internal bleeding
• D. Reposition the patient for comfort

Correct answer: C

Rationale: When a patient on anticoagulant therapy experiences sudden, severe back pain, the priority nursing action is to assess for signs of internal bleeding. Severe back pain in this context could be indicative of internal bleeding, such as a retroperitoneal bleed, which is a critical condition requiring immediate attention. Administering pain medication or applying a cold compress may mask or delay the identification of a potentially life-threatening situation. Repositioning the patient for comfort is not the priority when internal bleeding needs to be ruled out.

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