Nursing Elites

1. Which risk factor places patients and residents at the greatest risk for falls?

• A. Old age
• B. Middle age
• C. Pneumonia
• D. COPD

Correct answer: A

Rationale: Old age is a significant risk factor for falls as elderly individuals are more prone to falls due to factors like decreased balance, muscle strength, and vision. Middle age is less associated with falls compared to old age. Pneumonia and COPD are medical conditions that are not direct risk factors for falls, unlike aging which significantly increases the risk of falls.

2. In a clinic in a primarily African American community, a higher incidence of uncontrolled hypertension is noted in patients. To correct this health disparity, what should the nurse do first?

• A. Initiate a regular home-visit program by clinic nurses.
• B. Schedule teaching sessions about low-salt diets at community events.
• C. Assess the perceptions of community members about the care at the clinic.
• D. Obtain low-cost antihypertensive drugs using government grant funding.

Correct answer: C

Rationale: To address the higher incidence of uncontrolled hypertension in the primarily African American community, the nurse should first assess the perceptions of community members about the care at the clinic. Understanding the community's perspective can provide valuable insights into the reasons behind the health disparity. Initiating a regular home-visit program or scheduling teaching sessions about low-salt diets are important interventions but should come after gathering information on community perceptions. Obtaining low-cost antihypertensive drugs is not the initial priority; understanding community perspectives is crucial for developing effective interventions.

3. While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?

• A. Abdominal respirations
• B. Inspiratory grunt
• C. Nasal flaring
• D. Cyanosis

Correct answer: A

Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.

4. What consideration is important when caring for a female Muslim patient?

• A. Make eye contact
• B. Provide long-sleeved gowns or allow her to use her own
• C. Touch while talking
• D. Assign male caregivers when possible

Correct answer: B

Rationale: When caring for a female Muslim patient, providing long-sleeved gowns or allowing her to use her own clothing is crucial. Most Muslim women prefer to cover their whole body, even during examinations. Offering long gowns with long sleeves or allowing the patient to use her own clothing respects her cultural and religious preferences. Making eye contact is not a common practice in some Muslim cultures, so it's important to be mindful of this and respect the patient's preferences. Touching while talking may not be culturally appropriate for some Muslim patients, so it's best to avoid it unless necessary. Assigning female caregivers is often preferred to respect the patient's modesty and religious beliefs. If a male caregiver or physician needs to interact with the patient, the patient's husband may request to be present in the room.

5. Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?

• A. Maintain a constant connection to low-intermittent suction
• B. Irrigate the tube as per physician's order
• C. Suction the mouth and nose every shift
• D. Perform a daily fecal occult blood sample

Correct answer: B

Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting. To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (Choice A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (Choice C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (Choice D) is unrelated to maintaining the patency of a nasogastric tube.

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