Nursing Elites

1. Which of the following are contraindications to salicylic acid therapy?

• A. Third trimester of pregnancy
• B. Thrombocytopenia
• C. Coronary artery disease
• D. Adolescents with chickenpox

Correct answer: A

Rationale: The correct answer is A: Third trimester of pregnancy. Salicylic acid is contraindicated during the third trimester of pregnancy due to the risk of complications for both the mother and the fetus. Thrombocytopenia (choice B) is not a contraindication to salicylic acid therapy. Coronary artery disease (choice C) is not a specific contraindication to salicylic acid therapy. However, caution should be exercised in patients with coronary artery disease due to the antiplatelet effects of salicylic acid. Adolescents with chickenpox (choice D) should not be given salicylic acid due to the risk of Reye Syndrome, a rare but serious illness.

2. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

• A. Tidaling with spontaneous respirations
• B. Drainage collection chamber is 1/3 full
• C. 1 cm of water present in the water seal chamber
• D. Suction chamber pressure of -20 cm H2O

Correct answer: C

Rationale: The correct answer is C. There should be 2 cm of water in the water seal chamber of the chest tube system. A level of 1 cm may indicate a leak or compromised functionality that requires intervention. Choices A, B, and D are not findings that necessarily require immediate intervention. Tidaling with spontaneous respirations is an expected finding, the drainage collection chamber being 1/3 full is within normal limits, and a suction chamber pressure of -20 cm H2O indicates appropriate suction for chest drainage.

3. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?

• A. Assessment
• B. Planning
• C. Implementation
• D. Evaluation

Correct answer: C

Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.

4. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding?

• A. Beef broth
• B. Oatmeal
• C. Apple juice
• D. Toast

Correct answer: B

Rationale: Oatmeal is a soft, easy-to-swallow food, making it appropriate for clients with dysphagia, as it minimizes the risk of aspiration compared to liquids or hard foods. Beef broth (Choice A) is a liquid and may pose a risk of aspiration. Apple juice (Choice C) is a liquid and can also be a choking hazard for individuals with dysphagia. Toast (Choice D) is a hard food that may be difficult for a client with dysphagia to swallow safely.

5. A client diagnosed with pneumonia is receiving oxygen therapy at 4 L/min via nasal cannula. Which of the following interventions is most important?

• A. Encourage fluid intake.
• B. Monitor oxygen saturation levels.
• C. Change the oxygen tubing daily.
• D. Assist with frequent position changes.

Correct answer: B

Rationale: Monitoring oxygen saturation levels is the most important intervention in this scenario. It ensures that the client is receiving adequate oxygenation, which is crucial for a client with pneumonia. By monitoring saturation levels, the nurse can promptly identify any oxygenation issues and adjust the oxygen delivery if necessary. Encouraging fluid intake, changing oxygen tubing daily, and assisting with frequent position changes are also important aspects of care for a client with pneumonia, but they are not as critical as monitoring oxygen saturation levels in ensuring immediate respiratory support.

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