Nursing Elites

1. A patient has been diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement?

• A. Encourage dairy alternatives.
• B. Monitor intake of vitamin D.
• C. Increase intake of caffeinated drinks.
• D. Assist the patient with daily activities.

Correct answer: B

Rationale: The correct intervention for a patient diagnosed with osteoporosis and lactose intolerance is to monitor their intake of vitamin D. Since the patient has lactose intolerance, encouraging dairy alternatives (Choice A) would not be appropriate. Increasing intake of caffeinated drinks (Choice C) is not beneficial for managing osteoporosis and may even have negative effects on bone health. Assisting the patient with daily activities (Choice D) is a general nursing intervention that may not directly address the specific needs related to osteoporosis and lactose intolerance.

2. When performing nasotracheal suctioning for a client with a respiratory infection, what technique should the nurse use?

• A. Apply intermittent suction when withdrawing the catheter
• B. Suction continuously while inserting the catheter
• C. Suction intermittently while inserting the catheter
• D. Use a Yankauer suction device

Correct answer: A

Rationale: When performing nasotracheal suctioning for a client with a respiratory infection, the nurse should apply intermittent suction when withdrawing the catheter. This technique helps minimize mucosal damage and is considered best practice. Choice B, suctioning continuously while inserting the catheter, is incorrect as continuous suctioning can cause trauma to the airway. Choice C, suctioning intermittently while inserting the catheter, is also incorrect as it can increase the risk of hypoxia and mucosal damage. Choice D, using a Yankauer suction device, is not appropriate for nasotracheal suctioning as it is typically used for oral suctioning. Therefore, the correct technique is to apply intermittent suction when withdrawing the catheter to ensure effective and safe suctioning.

3. An older adult client appears agitated when the nurse requests that the client’s dentures be removed prior to surgery and states, “I never go anywhere without my teeth.” Which of the following is an appropriate nursing response?

• A. You should comply with the request
• B. You seem worried. Are you concerned someone may see you without your teeth?
• C. I will call your family to discuss this
• D. It’s not a big deal; just remove them

Correct answer: B

Rationale: The appropriate nursing response in this situation is to acknowledge and address the client's concerns empathetically. By expressing understanding and asking if the client is worried about being seen without their teeth, the nurse shows empathy and attempts to alleviate the client's anxiety. Choice A is incorrect as it dismisses the client's feelings. Choice C is inappropriate as it does not directly address the client's agitation. Choice D is not the best response as it minimizes the client's feelings and does not provide emotional support.

4. A client with a terminal illness is expected to pass away within 24 hours. The family asks the nurse about what to expect at this time. Which of the following findings should the nurse include?

• A. Regular breathing pattern
• B. Warm extremities
• C. Increased urine output
• D. Decreased muscle tone

Correct answer: D

Rationale: As death approaches, decreased muscle tone and other signs like decreased blood pressure, irregular breathing patterns, cold extremities, and decreased urine output are common. Warm extremities (choice B) would not be expected as circulation may be compromised. Increased urine output (choice C) is unlikely as organ function declines. A regular breathing pattern (choice A) is also unlikely as irregular breathing patterns are common near death.

5. A client reports abdominal pain. An assessment by the nurse reveals a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Overdue menses

Correct answer: A

Rationale: The nurse's priority should be the client's temperature. A high temperature of 39.2 degrees C (102 degrees F) indicates a potential infection or inflammation that requires immediate attention. While heart rate and abdominal tenderness are important assessments, the temperature takes precedence as it signals a more urgent issue. Overdue menses, although significant, are not the priority in this scenario when compared to the possibility of an acute infection or inflammatory process.

Similar Questions