Nursing Elites

1. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.

2. What are the complications of untreated hypertension?

• A. Heart disease and stroke
• B. Kidney failure and vision loss
• C. Pulmonary embolism and arrhythmias
• D. Blood clots and gastrointestinal bleeding

Correct answer: A

Rationale: The correct answer is A: 'Heart disease and stroke.' Untreated hypertension can lead to various complications, including heart disease and stroke. These are common outcomes of long-term high blood pressure. Choice B, 'Kidney failure and vision loss,' is incorrect as kidney failure and vision loss are more commonly associated with diabetic complications rather than untreated hypertension. Choice C, 'Pulmonary embolism and arrhythmias,' while serious, are not among the primary complications of untreated hypertension. Choice D, 'Blood clots and gastrointestinal bleeding,' are not typical complications of untreated hypertension but can occur due to other conditions such as blood clotting disorders or gastrointestinal diseases.

3. What is the priority nursing action for a patient with an acute asthma attack?

• A. Administer a bronchodilator
• B. Monitor oxygen saturation
• C. Position the patient in a high Fowler's position
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer a bronchodilator. During an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators are the first-line treatment for asthma attacks as they help dilate the bronchioles, allowing for better airflow. Monitoring oxygen saturation is important but not the priority when the patient is in distress. Placing the patient in a high Fowler's position can help with breathing but is not the initial priority. Calling for assistance can be done after initiating the appropriate treatment.

4. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, 'I am very upset and I want to be alone for a little while.' Which of the following responses should the nurse make?

• A. I see that you are feeling overwhelmed. I will come back when you are ready
• B. This is normal, and I will check on you later
• C. You are feeling frustrated. Let's talk about your concerns.
• D. You will feel better soon. Let me get you some water.

Correct answer: A

Rationale: Acknowledging the client's feelings and allowing them space demonstrates understanding and respect for their emotions.

5. Which symptom would indicate a complication after a subdural hematoma?

• A. Increased appetite
• B. Decreased level of consciousness
• C. High-pitched cry
• D. Bulging posterior fontanelle

Correct answer: B

Rationale: A bulging posterior fontanelle is a sign of increased intracranial pressure in infants, not a common symptom after a subdural hematoma. In the context of a subdural hematoma, a decreased level of consciousness is more indicative of a complication as it can be a sign of worsening brain function due to increased pressure on the brain from the collection of blood in the subdural space. Increased appetite and high-pitched cry are not typically associated with complications of a subdural hematoma.

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