Nursing Elites

1. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place the client's left arm on a pillow while he is sitting.
• B. Provide total care in assisting with the client's ADLs.
• C. Encourage mobility and avoid bed rest.
• D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.

Correct answer: A

Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.

2. A client requests the creation of a living will. Which of the following actions should the nurse take?

• A. Schedule a meeting between the hospital ethics committee and the client.
• B. Evaluate the client's understanding of life-sustaining measures.
• C. Determine the client's preferences about post-mortem care.
• D. Request a conference with the client's family

Correct answer: B

Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.

3. When applying Nagele's rule, a healthcare professional is estimating a client's expected date of delivery based on their last menstrual period, which began on April 12th. What date should the healthcare professional determine to be the client's expected delivery date? (Use mmdd format.)

• A. 119
• B. 121
• C. 115
• D. 122

Correct answer: A

Rationale: To calculate the expected delivery date using Nagele's rule, begin by subtracting 3 months from the first day of the last menstrual period (April 12th), which results in January 12th. Then, add 7 days. Therefore, the expected delivery date would be January 19th (0119). This calculation method helps healthcare professionals estimate the client's due date.

4. What is the correct sequence for assessing the abdomen?

• A. Tympanic percussion, measurement of abdominal girth, and inspection
• B. Assessment for distention, tenderness, and discoloration around the umbilicus
• C. Percussion, palpation, and auscultation
• D. Auscultation, percussion, and palpation

Correct answer: D

Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.

5. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. High platelets
• B. Hypertension
• C. Lower platelets
• D. High temperatures

Correct answer: C

Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.

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