Nursing Elites

1. Inspiratory and expiratory stridor may be heard in a client who:

• A. Is experiencing an exacerbation of goiter
• B. Is experiencing an acute asthmatic attack
• C. Has aspirated a piece of meat
• D. Has severe laryngotracheitis

Correct answer: D

Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.

2. Which intervention is most appropriate when caring for a patient experiencing a tonic-clonic seizure?

• A. Restrain the patient to prevent injury
• B. Place a tongue depressor in the patient's mouth
• C. Turn the patient to the side to maintain an open airway
• D. Attempt to stop the seizure by holding the patient’s arms

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority is to ensure patient safety by maintaining an open airway to prevent aspiration. Turning the patient to the side helps achieve this goal by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration. Restraint can lead to injury, placing a tongue depressor can cause harm or obstruct the airway further, and attempting to stop the seizure by holding the patient's arms is ineffective and can also result in injury. Therefore, the most appropriate intervention is to turn the patient to the side.

3. A client is recovering from abdominal surgery and has a nasogastric (NG) tube in place. The nurse notes that the client is experiencing nausea despite the NG tube being patent. What is the nurse's best action?

• A. Increase the suction on the NG tube.
• B. Administer an antiemetic as prescribed.
• C. Irrigate the NG tube with saline.
• D. Reposition the client to the left side.

Correct answer: B

Rationale: Administering an antiemetic as prescribed is the best action for the nurse to take when a client with a patent NG tube is experiencing nausea. This intervention can help relieve nausea effectively. Increasing suction on the NG tube (Choice A) may not address the underlying cause of the nausea and could potentially lead to complications. Irrigating the NG tube with saline (Choice C) is not indicated for addressing nausea in this scenario. Repositioning the client to the left side (Choice D) is not the priority intervention for nausea in a client with a patent NG tube.

4. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

5. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?

• A. Recommend parents bring favorite snacks
• B. Encourage ambulation daily to the playroom
• C. Measure blood pressure every 4 to 6 hours
• D. Offer a selection of fresh fruit for each meal

Correct answer: C

Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.

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