Nursing Elites

1. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

2. A client with acute diverticulitis is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the instructions?

• A. I will avoid eating fiber until this condition resolves
• B. I will take a laxative daily
• C. I will receive the nutrients I need through my IV fluids
• D. I will eat only solid foods

Correct answer: A

Rationale: The correct answer is A. During acute diverticulitis, avoiding fiber is essential as it helps reduce irritation of the intestines. Choice B is incorrect because taking a laxative daily can exacerbate diverticulitis. Choice C is incorrect as IV fluids mainly provide hydration and electrolytes, not all essential nutrients. Choice D is incorrect because during acute diverticulitis, a low-fiber or liquid diet is typically recommended to rest the bowel.

3. A client receiving chemotherapy has developed stomatitis. Which of the following interventions should the nurse implement?

• 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 intervention for a client with stomatitis is to encourage them to eat soft foods. Soft foods help prevent further irritation of the mouth, making it easier for the client to eat and reducing discomfort. Providing lemon-glycerin swabs could be too harsh on the already irritated mucosa. Avoiding toothpaste is relevant for clients with stomatitis to prevent further irritation. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol can further irritate the mucosa.

4. Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?

• A. Insert the suction catheter while the client is swallowing
• B. Apply intermittent suction when withdrawing the catheter
• C. Place the catheter in a clean, dry location for later use
• D. Hold the suction catheter with the non-dominant hand

Correct answer: B

Rationale: The correct technique when performing nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps reduce trauma to the mucosa by preventing prolonged suctioning. Choice A is incorrect because inserting the suction catheter while the client is swallowing may increase the risk of aspiration. Choice C is incorrect as placing the catheter in a clean, dry location for later use is not a safe practice as it can lead to contamination. Choice D is incorrect since it does not address the proper technique involved in nasotracheal suctioning.

5. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

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