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. A nurse is assisting in the admission of a young adult female Korean exchange student with acute abdominal pain. When asked about her sexual activity, she looks away. What should the nurse do?

• A. Omit this question from the assessment form
• B. Ask her if she would like an interpreter present to assist with communication
• C. Reword the question to ensure the client's understanding
• D. Watch the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to a different question can help gauge her comfort level and understanding, which is essential in culturally sensitive care. By watching her response to a different question, the nurse can assess if the discomfort is related to the specific question or a broader issue. Omitting the question may result in missing crucial information. Asking about an interpreter assumes that the language barrier is the only issue, which may not be the case. Rewording the question may not address the underlying discomfort and could still lead to misinterpretation.

3. What is the primary purpose of administering Rho(D) immune globulin (RhoGAM) to an Rh-negative mother after childbirth?

• A. To prevent Rh sensitization in future pregnancies
• B. To treat anemia in the newborn
• C. To increase the mother's white blood cell count
• D. To prevent infection in the newborn

Correct answer: A

Rationale: The correct answer is A: To prevent Rh sensitization in future pregnancies. RhoGAM is given to an Rh-negative mother to prevent the development of antibodies against Rh-positive blood cells. This prevents Rh sensitization, which could lead to hemolytic disease in future Rh-positive pregnancies. Choices B, C, and D are incorrect because RhoGAM is not used to treat anemia in the newborn, increase the mother's white blood cell count, or prevent infection in the newborn.

4. An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the PN document as evidence that the amount of insulin is inadequate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dL
• D. Reports nausea in the morning but can still eat breakfast

Correct answer: C

Rationale: The correct answer is C. High evening glucose levels indicate that the morning dose of NPH insulin may be insufficient to control blood sugar throughout the day. Choice A is incorrect as cold and numb feet are more indicative of a circulation issue rather than an insulin inadequacy. Choice B suggests a wound infection rather than inadequate insulin. Choice D, nausea in the morning, may be due to other causes and does not necessarily indicate inadequate insulin dosage.

5. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.

Similar Questions