Nursing Elites

1. A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?

• A. Have the client lie down after meals
• B. Encourage the client to speak while eating
• C. Have the client sit upright for 1 hour following meals
• D. Offer thin liquids with meals

Correct answer: C

Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour following meals. This position facilitates swallowing and reduces the risk of aspiration. Choice A is incorrect because having the client lie down after meals can increase the risk of aspiration. Choice B is incorrect as talking while eating can lead to choking. Choice D is incorrect as thin liquids may be harder for a client with dysphagia to swallow safely.

2. What is the first action when a client who is admitted with schizophrenia reports hearing voices telling them to harm themselves?

• A. Administer antipsychotic medication
• B. Ask the client what the voices are saying
• C. Distract the client with another activity
• D. Call the healthcare provider

Correct answer: B

Rationale: The correct first action when a client with schizophrenia reports hearing voices telling them to harm themselves is to ask the client what the voices are saying. This is important to assess the content of the hallucinations and determine if there is any immediate danger or suicidal intent. Administering antipsychotic medication without knowing the content of the voices or the level of danger could be inappropriate and potentially harmful. Distracting the client with another activity may not address the underlying issue of the hallucinations commanding harm. Calling the healthcare provider can be done after assessing the situation and gathering information from the client.

3. A healthcare provider is preparing to administer an influenza vaccine to an adult client. Which of the following is a contraindication?

• A. Client has a low-grade fever
• B. Client is allergic to eggs
• C. Client had recent surgery
• D. Client is on corticosteroid therapy

Correct answer: B

Rationale: The correct answer is B: Client is allergic to eggs. The influenza vaccine is contraindicated in individuals with an allergy to eggs because some influenza vaccines are produced using egg-based processes. Choices A, C, and D are not contraindications for administering the influenza vaccine. A low-grade fever, recent surgery, and corticosteroid therapy are not contraindications for receiving the influenza vaccine.

4. A client has been prescribed vasopressin for the treatment of diabetes insipidus. What is the expected pharmacological action of this medication?

• A. To stimulate the pancreas to secrete insulin
• B. To slow the absorption of glucose in the intestine
• C. To increase reabsorption of water in the renal tubules
• D. To increase blood pressure

Correct answer: C

Rationale: The correct answer is C: To increase reabsorption of water in the renal tubules. Vasopressin mimics the action of antidiuretic hormone (ADH) by increasing the reabsorption of water in the renal tubules. This leads to decreased urine output, helping to manage symptoms of diabetes insipidus, which is characterized by excessive thirst and urination. Choices A, B, and D are incorrect. Vasopressin does not stimulate the pancreas to secrete insulin, slow the absorption of glucose in the intestine, or directly increase blood pressure.

5. A nurse is assessing a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Desmopressin can cause fluid retention, so monitoring the client's weight is crucial to detect signs of water intoxication or overhydration, which can occur with the medication. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin use in diabetes insipidus. Carbohydrate intake (choice B) is important for diabetes management but is not specifically relevant to monitoring desmopressin therapy. Hematocrit (choice C) is not typically influenced by desmopressin use in diabetes insipidus.

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