Nursing Elites

1. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?

• A. Apply a moisturizing cream to the affected areas.
• B. Encourage the client to consume foods rich in vitamin B.
• C. Notify the healthcare provider for further evaluation.
• D. Ensure that the client gets adequate B vitamins in foods or supplements.

Correct answer: D

Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.

2. The nurse is planning care for a 16-year-old with juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscles. Which physical therapy regimen should the nurse encourage the adolescent to implement?

• A. Exercise in a swimming pool.
• B. Splint affected joints during activity.
• C. Perform passive range of motion exercises twice daily.
• D. Begin a training program of lifting weights and running.

Correct answer: A

Rationale: Exercising in a swimming pool is beneficial for adolescents with juvenile rheumatoid arthritis as it reduces stress on the joints while allowing movement and strengthening. The buoyancy of water supports the body, making exercises easier and less painful, while also providing resistance to strengthen muscles. This form of exercise can help improve joint mobility and overall function without causing excessive strain on the joints. Choices B, C, and D are incorrect because splinting affected joints, performing passive range of motion exercises, or beginning a training program of lifting weights and running can potentially exacerbate symptoms and cause additional stress on the joints, which is not recommended for individuals with juvenile rheumatoid arthritis.

3. A client with chronic pain is prescribed a fentanyl (Duragesic) patch. Which instruction should the nurse provide to the client?

• A. Apply the patch to a clean, dry, and hairless area of the skin.
• B. Use a heating pad over the patch to enhance absorption.
• C. Change the patch daily to maintain effectiveness.
• D. Place the patch on the same site with each application.

Correct answer: A

Rationale: The correct instruction for applying a fentanyl (Duragesic) patch is to place it on a clean, dry, and hairless area of the skin. This ensures proper adhesion of the patch and optimal absorption of the medication. Using a heating pad over the patch is contraindicated as it can increase drug absorption and lead to overdose. Changing the patch daily is necessary for some medications, but fentanyl patches are usually changed every 72 hours to maintain a steady blood level of the medication. Placing the patch on the same site with each application can lead to skin irritation, uneven drug absorption, and should be avoided to allow the skin to recover between applications.

4. A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. Bleeding time
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Partial thromboplastin time (PTT). Heparin affects the intrinsic pathway of the coagulation cascade, which is reflected by changes in the PTT. Monitoring the PTT helps ensure that the patient's blood is within the desired therapeutic range and prevents complications related to clotting or bleeding. Prothrombin time (PT) primarily assesses the extrinsic pathway and is not as sensitive to heparin therapy. Bleeding time and platelet count are not specific tests for monitoring the effectiveness of heparin therapy in DVT.

5. What action should the nurse take to prevent tracheal tissue damage in a client with a tracheostomy?

• A. Secure the tracheostomy ties firmly.
• B. Change the tracheostomy tube daily.
• C. Use the minimal leak technique when inflating the cuff.
• D. Clean the stoma with hydrogen peroxide.

Correct answer: C

Rationale: To prevent tracheal tissue damage in a client with a tracheostomy, the nurse should use the minimal leak technique when inflating the cuff. This method helps avoid excessive pressure on the tracheal tissue, thereby reducing the risk of damage. Choice A is incorrect because securing the tracheostomy ties too tightly can cause pressure and tissue damage. Choice B is incorrect as changing the tracheostomy tube daily is not necessary unless there is a specific clinical indication. Choice D is incorrect as cleaning the stoma with hydrogen peroxide can irritate the skin and mucous membranes, potentially leading to damage.

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