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. For whom is the community health nurse primarily responsible?

• A. individuals
• B. populations
• C. families
• D. class E citizens

Correct answer: B

Rationale: Community health nurses are primarily responsible for populations. While they do provide care and support to individuals and families within the community, their focus is on the health and well-being of entire populations. Choice A is incorrect as the primary responsibility is broader than just individuals. Choice C is incorrect as families are part of the population but not the sole focus. Choice D, 'class E citizens', is too specific and not a standard term in public health, making it an incorrect choice.

3. A client with multiple sclerosis is receiving baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?

• A. Hypertension
• B. Muscle spasms
• C. Drowsiness
• D. Tachycardia

Correct answer: C

Rationale: The correct answer is C: Drowsiness. Baclofen, a muscle relaxant commonly used to treat conditions like multiple sclerosis, can cause drowsiness as a side effect. Monitoring for drowsiness is important to ensure the client's safety and well-being. Choice A, Hypertension, is incorrect because baclofen is not known to cause hypertension. Choice B, Muscle spasms, is not a common side effect of baclofen but rather the symptom it is used to treat. Choice D, Tachycardia, is also incorrect as baclofen is not associated with causing an increase in heart rate.

4. When assisting a family who fails to take action during a sick member despite suggestions, you will:

• A. explain the consequences of inaction
• B. identify the courses of action open to the family and the resources needed for each
• C. discuss the consequences of each course of action available
• D. influence the family to act on what you think is best for the situation

Correct answer: B

Rationale: When helping a family decide on actions to take, it is essential to identify the courses of action available to them and the resources needed for each. This empowers the family to make informed decisions based on their specific situation. Explaining the consequences of inaction (Choice A) may be necessary but does not provide a range of options. Discussing the consequences of each course of action (Choice C) is important but does not actively guide the family on the available actions. Influencing the family (Choice D) to act based on personal judgment undermines their autonomy and may not lead to the best outcome.

5. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

• A. Expiratory wheezes
• B. Blurred vision
• C. Ascites
• D. Dilated pupils

Correct answer: C

Rationale: Ascites is a common finding in clients with portal hypertension. Portal hypertension results in increased pressure in the portal vein, leading to the development of ascites, which is the accumulation of fluid in the abdominal cavity. Expiratory wheezes (Choice A) are associated with respiratory conditions. Blurred vision (Choice B) is more commonly linked to eye disorders or neurological issues. Dilated pupils (Choice D) can be related to neurological conditions or drug effects, but not specifically to portal hypertension.

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