Nursing Elites

1. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

• A. Elevated temperature
• B. Generalized weakness
• C. Diminished lung sounds
• D. Pain when swallowing

Correct answer: D

Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.

2. A woman with chronic osteoarthritis is complaining of knee pain. Which pathophysiological process is contributing to her pain?

• A. Inflammation of the synovial membrane.
• B. Degeneration of the cartilage in the joint.
• C. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
• D. Formation of uric acid crystals in the joint space.

Correct answer: C

Rationale: The correct answer is C. In osteoarthritis, the breakdown of cartilage in the joints leads to chondrocyte injury, which results in the destruction of joint cartilage and the production of osteophytes. This process causes joint inflammation and pain. Choice A is incorrect because osteoarthritis primarily involves the articular cartilage rather than the synovial membrane. Choice B is incorrect as it describes the degeneration of cartilage but does not explain the specific pathophysiological process contributing to pain in osteoarthritis. Choice D is incorrect as the formation of uric acid crystals is characteristic of gout, not osteoarthritis.

3. A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?

• A. Fresh fruits
• B. Processed cheese
• C. Whole grain bread
• D. Fresh vegetables

Correct answer: B

Rationale: The correct answer is B: Processed cheese. Processed cheese is high in sodium and should be avoided in a low-sodium diet for clients with hypertension. Fresh fruits, whole grain bread, and fresh vegetables are generally low in sodium and can be part of a healthy diet for clients with hypertension.

4. What is a priority action for the nurse when caring for a client with suspected meningitis?

• A. Isolate the client in a private room
• B. Administer intravenous antibiotics
• C. Obtain a throat culture
• D. Perform a chest x-ray

Correct answer: B

Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.

5. While assisting a female client to the toilet, the client begins to have a seizure, and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

• A. Document details of the seizure activity.
• B. Observe for lacerations on the tongue.
• C. Observe for prolonged periods of apnea.
• D. Evaluate for evidence of incontinence.

Correct answer: A

Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.

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