Nursing Elites

1. A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?

• A. I will monitor my husband for coughing while he is eating
• B. I will monitor my husband for pocketing food in his mouth
• C. I will monitor for a change in my husband's voice after he swallows
• D. I will monitor my husband for tilting his head forward when he swallows

Correct answer: D

Rationale: The correct answer is D. Tilting the head forward during swallowing is not a compensatory technique for dysphagia and may increase the risk of aspiration. Choices A, B, and C are correct statements indicating appropriate monitoring for manifestations of dysphagia: coughing while eating, pocketing food in the mouth, and changes in voice after swallowing are all signs that should be monitored.

2. A client with a history of falls is being admitted to the unit. What intervention should the nurse implement first?

• A. Increase the client's medication to ensure they don't fall.
• B. Use bed alarms to monitor the client's movements.
• C. Encourage the client to use a walker for mobility.
• D. Assign the client to a nursing assistant for supervision.

Correct answer: B

Rationale: The correct answer is B: 'Use bed alarms to monitor the client's movements.' When a client with a history of falls is admitted, the nurse's initial intervention should focus on fall prevention measures. Using bed alarms to monitor the client's movements can help alert the healthcare team if the client attempts to get out of bed and reduce the risk of falls. Choice A is incorrect because increasing medication should not be the first intervention as it may not address the underlying causes of falls and can have adverse effects. Choice C may be appropriate but is not the priority over implementing safety measures like bed alarms. Choice D is incorrect as assigning the client to a nursing assistant for supervision alone may not be as effective as utilizing bed alarms for continuous monitoring.

3. A nurse is assessing the skin of an immobilized patient. What will the nurse do?

• A. Use a standardized tool such as the Braden Scale.
• B. Limit the amount of fluid intake.
• C. Have special times for inspection so as not to interrupt routine care.
• D. Assess the skin every 4 hours.

Correct answer: A

Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.

4. After a case manager completes a history and physical assessment for a client with COPD, which of the following actions should the case manager take next?

• A. Call the provider with a list of client concerns.
• B. Identify the client's current health needs.
• C. Compile a list of community resources for the client.
• D. Refer the client to a COPD support group.

Correct answer: A

Rationale: After completing a history and physical assessment for a client with COPD, the next step for the case manager should be to call the provider with a list of client concerns. This is crucial as the provider needs to be informed about any issues or changes in the client's health status to ensure appropriate management. Identifying the client's current health needs, as mentioned in option B, is important but would typically follow after communicating the client's concerns to the provider. Compiling a list of community resources (option C) and referring the client to a COPD support group (option D) are also valuable actions but are not the immediate next steps after completing the assessment.

5. What is the most appropriate action for handling hazardous drugs?

• A. Wear gloves and wash hands after handling.
• B. Store the drugs according to manufacturer instructions.
• C. Discard unused drugs in regular trash.
• D. Wear personal protective equipment (PPE) when handling hazardous drugs.

Correct answer: D

Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.

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