Nursing Elites

1. An 82-year-old female client with type 2 diabetes and degenerative arthritis complains to the nurse that she has a hard time cutting her toenails. What should the nurse recommend?

• A. Seek routine nail care with a podiatrist.
• B. Encourage monthly pedicures at a nail salon.
• C. Soak feet for 10 minutes before cutting nails.
• D. Ask a family member to cut toenails.

Correct answer: A

Rationale: For an 82-year-old female client with type 2 diabetes and degenerative arthritis, the nurse should recommend seeking routine nail care with a podiatrist. This is crucial to ensure proper and safe toenail care, reducing the risk of injury and infection, which is especially important for diabetic clients. Encouraging monthly pedicures at a nail salon (choice B) may not address the underlying issues related to diabetes and arthritis. Soaking feet for 10 minutes before cutting nails (choice C) may help soften the nails but does not address the difficulty the client faces in cutting them. Asking a family member to cut toenails (choice D) may not guarantee the expertise needed for proper diabetic foot care, which a podiatrist can provide.

2. What should the nurse caring for a 6-year-old child with acute glomerulonephritis anticipate as the most challenging aspect of care to implement?

• A. Forced fluids
• B. Increased feedings
• C. Bed rest
• D. Frequent position changes

Correct answer: C

Rationale: The correct answer is C: Bed rest. During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required. Bed rest can be very challenging to implement with an active 6-year-old child. Forced fluids (choice A) may be necessary to maintain hydration. Increased feedings (choice B) may not be as difficult to implement as bed rest. Frequent position changes (choice D) may also be important but are not typically the most challenging aspect of care for a child with acute glomerulonephritis.

3. The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?

• A. Flush the tube with 50 mL of normal saline every 8 hours
• B. Clamp the tube when not in use
• C. Position the client in a supine position
• D. Verify tube placement by checking pH of gastric contents

Correct answer: D

Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.

4. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?

• A. Every 2 months
• B. Every 4 months
• C. Every 6 months
• D. Every 8 months

Correct answer: C

Rationale: Children with ADHD who are on long-term medication therapy should be assessed for side effects every 6 months. This timeframe allows healthcare providers to monitor the effects of the medication and make any necessary adjustments. Checking every 2 months (Choice A) may be too frequent and not practical for routine monitoring, while checking every 4 or 8 months (Choices B and D) may lead to missing potential side effects or delays in addressing them.

5. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

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