Nursing Elites

1. A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?

• A. Anorexia
• B. Aspiration
• C. Self-care deficit
• D. Inadequate intake

Correct answer: B

Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (Choice A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (Choice C) and inadequate intake (Choice D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.

2. A client is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse?

• A. Assist the client to shower as ordered and monitor the site for further changes
• B. Instruct the client to lie prone to allow the site to dry
• C. Place antibiotic ointment and a sterile dressing over the site
• D. Notify the physician for an antibiotic order

Correct answer: A

Rationale: An incision that appears slightly red with a small amount of serous drainage on the first day following surgery is going through a normal healing process. It is important to keep the incision clean. In this case, the nurse should assist the client to shower as ordered to maintain hygiene and monitor for changes in the incision site. Instructing the client to lie prone may not be necessary and could cause discomfort. Applying antibiotic ointment without a specific order is not recommended as it can interfere with the healing process. Notifying the physician for an antibiotic order is premature at this stage since the incision is showing normal signs of healing.

3. The nurse should wash from the ________________________ when washing a patient's eye area.

• A. outer canthus to the inner canthus
• B. inner canthus to the outer canthus
• C. internal nares to the external nares
• D. external nares to the internal nares

Correct answer: B

Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.

4. What is the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance, as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well?"? The patient will:

• A. demonstrate improved social skills
• B. express a desire to interact with others
• C. become more independent in decision-making
• D. select and participate in one group activity per day

Correct answer: D

Rationale: The correct outcome for the patient with impaired social interaction related to sociocultural dissonance is to select and participate in one group activity per day. This outcome focuses on increasing social involvement, which aligns with addressing the nursing diagnosis. The patient has already expressed a desire to interact with others, so the goal is to facilitate actual participation in social activities. Becoming more independent in decision-making and demonstrating improved social skills are not directly related to the specific nursing diagnosis provided. Additionally, the outcomes must be measurable, making choices A and C less appropriate as they lack specificity and measurability.

5. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

• A. UAP splint the patient's chest during coughing.
• B. UAP assist the patient to ambulate to the bathroom.
• C. UAP help the patient to a bedside chair for meals.
• D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: D

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

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