Nursing Elites

1. When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?

• A. Ensure that adequate mist is supplied
• B. Inspect the nares and ears for skin breakdown
• C. Lubricate the tips of the cannula before insertion
• D. Maintain sterile technique when handling the cannula

Correct answer: B

Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.

2. A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?

• A. 16% increase in overall body fat.
• B. Reduced melanin production.
• C. Thinning of the skin with loss of elasticity.
• D. Calcium loss in the bones.

Correct answer: C

Rationale: Thinning of the skin with loss of elasticity is the physical characteristic of aging that contributes to an increased risk of developing decubitus ulcers. As individuals age, the skin becomes thinner and loses its elasticity, making it more susceptible to damage from pressure, leading to the formation of pressure ulcers. Choices A, B, and D are incorrect as they do not directly contribute to the development of decubitus ulcers in this context.

3. A male client is brought to the emergency department as the result of a motorcycle accident. He was not wearing a helmet at the time of the accident and states that he has no intention of ever wearing one. Within the framework of the Transtheoretical Model (TTM), which response should the nurse provide?

• A. Wearing a helmet or not is certainly an individual decision.
• B. You should seriously consider wearing a helmet.
• C. Riding a motorcycle with a helmet increases your safety.
• D. I really think you don't have the facts about helmet use.

Correct answer: C

Rationale: Providing information on safety aligns with the TTM framework.

4. Which individual has the highest risk of developing community-acquired pneumonia?

• A. A 40-year-old first-grade teacher who works with underprivileged children.
• B. A 75-year-old retired secretary with exercise-induced wheezing.
• C. A 60-year-old homeless person who is an alcoholic and smokes.
• D. A 35-year-old aerobics instructor who skips meals and eats only vegetables.

Correct answer: C

Rationale: The correct answer is the 60-year-old homeless person who is an alcoholic and smokes. This individual has the highest risk of developing community-acquired pneumonia due to factors such as homelessness, alcoholism, and smoking, which weaken the immune system and make them more susceptible to respiratory infections. Choice A is incorrect as working with underprivileged children, while potentially exposing the individual to various illnesses, does not directly increase the risk of pneumonia. Choice B is less likely as exercise-induced wheezing may suggest asthma but does not directly correlate with pneumonia risk. Choice D, an aerobics instructor who eats only vegetables and skips meals, does not have the same level of risk factors for pneumonia as the homeless person in choice C.

5. A client with acute pancreatitis is experiencing severe abdominal pain. The nurse should implement which of the following interventions?

• A. Encourage oral intake
• B. Administer opioid analgesics
• C. Apply a heating pad to the abdomen
• D. Place the client in a supine position

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis experiencing severe abdominal pain is to administer opioid analgesics. Opioids are effective in managing the severe pain associated with acute pancreatitis. Encouraging oral intake may exacerbate the symptoms and is contraindicated due to the need for bowel rest. Applying a heating pad to the abdomen can worsen inflammation and should be avoided. Placing the client in a supine position may not provide relief and could potentially lead to increased discomfort.

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