Nursing Elites

1. Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?

• A. A young adult with a history of Down syndrome
• B. A teenager who reads at a 4th-grade level
• C. An elderly client with numerous arthritic nodules on the hands
• D. A preschooler with intermittent alertness

Correct answer: D

Rationale: The correct answer is D, a preschooler with intermittent alertness. This client may not have the cognitive ability to effectively use a PCA pump due to their age and alertness level. They may not understand how to self-administer the analgesia. Choices A, B, and C are more appropriate candidates for PCA as they are likely to have better comprehension and ability to operate the PCA pump compared to a preschooler with intermittent alertness.

2. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?

• A. Avoid chocolate and cheese
• B. Take frequent naps
• C. Take the medication with milk
• D. Avoid walking without assistance

Correct answer: A

Rationale: The correct answer is to avoid chocolate and cheese. MAO inhibitors can interact with tyramine-rich foods like these, potentially leading to severe hypertension. Choices B, C, and D are incorrect because taking frequent naps, taking the medication with milk, and avoiding walking without assistance are not relevant precautions associated with MAO inhibitors.

3. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is crucial in this situation as coughing while consuming liquids can indicate a risk of aspiration. Assessing the gag reflex can help determine if the client is safe to swallow without inhaling fluids into the lungs, which could lead to further respiratory complications. Adding a thickening agent may not address the underlying issue of aspiration risk. Feeding the client only solid foods is not appropriate without assessing the swallowing safety first. Increasing the rate of intravenous fluids does not directly address the client's difficulty with liquid intake.

4. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

5. A client with a history of seizures is being monitored with an electroencephalogram (EEG). Which of these interventions should the nurse perform to prepare the client for the test?

• A. Instruct the client to avoid caffeine for 8 hours before the test
• B. Explain the procedure to the client and obtain consent
• C. Administer anticonvulsant medication as ordered
• D. Instruct the client to wash their hair the morning of the test

Correct answer: A

Rationale: Instructing the client to avoid caffeine for 8 hours before the EEG is essential. This intervention helps ensure accurate test results by preventing stimulation of the nervous system, which could interfere with the interpretation of the brain's electrical activity. Explaining the procedure and obtaining consent are important steps but do not directly impact the test results. Administering anticonvulsant medication as ordered is a medical intervention and not a preparation step for the test. Instructing the client to wash their hair the morning of the test is not necessary for EEG preparation.

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