Nursing Elites

1. A patient is receiving chemotherapy and has developed stomatitis. Which of the following dietary recommendations should the nurse make?

• A. Eat salty foods to stimulate salivation.
• B. Avoid spicy foods.
• C. Increase intake of high-fiber foods.
• D. Consume cold foods to soothe the mucosa.

Correct answer: D

Rationale: Correct choice: Consume cold foods to soothe the mucosa. Cold foods can help soothe the mucosa and reduce discomfort for patients with stomatitis caused by chemotherapy.\nIncorrect choices: A) Salty foods may irritate the mucosa further. B) Spicy foods can increase discomfort and irritation. C) High-fiber foods may be rough and abrasive, exacerbating the condition.

2. A healthcare provider is assessing a client who has COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following findings should the provider report?

• A. Oxygen saturation of 95%.
• B. Productive cough with clear sputum.
• C. Respiratory rate of 22/min.
• D. Client reports dyspnea.

Correct answer: D

Rationale: The correct answer is D. Dyspnea in a client with COPD receiving oxygen should be reported as it may indicate worsening respiratory status. Oxygen saturation of 95% is within the expected range for a client receiving oxygen therapy and does not require immediate reporting. A productive cough with clear sputum is a common symptom in clients with COPD and does not necessarily warrant urgent reporting. A respiratory rate of 22/min is also within normal limits and does not raise immediate concerns in this scenario.

3. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased skin turgor.
• C. Tachycardia.
• D. Bounding pulse.

Correct answer: C

Rationale: The correct answer is C: Tachycardia. Tachycardia is a common sign of dehydration because the body tries to compensate for the reduced fluid volume by increasing the heart rate. Bradycardia (choice A) is not typically seen in dehydration as the body tries to maintain perfusion. Increased skin turgor (choice B) is actually a sign of dehydration, but tachycardia is a more specific finding. A bounding pulse (choice D) is associated with conditions like hyperthyroidism or aortic regurgitation, not dehydration.

4. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

• A. Keep the head of the bed elevated to 30 degrees.
• B. Administer IV antibiotics prophylactically.
• C. Change the catheter insertion site every 24 hours.
• D. Monitor the insertion site for redness.

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

5. A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?

• A. Massage the injection site after administering the medication.
• B. Insert the needle at a 45° angle.
• C. Use a Z-track technique to administer the injection.
• D. Aspirate for blood before injecting the medication.

Correct answer: C

Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.

Similar Questions