Nursing Elites

1. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?

• A. Hoarseness of the voice
• B. Slight swelling at the incision site
• C. Tingling around the mouth
• D. Mild fever

Correct answer: C

Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.

2. What is the function of the cervix in reproduction?

• A. Accepts and interprets signals of sexual stimuli
• B. Secretes mucus to facilitate sperm transport
• C. Serves as the site for union of ovum and sperm
• D. Receives the penis during intercourse

Correct answer: B

Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.

3. The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?

• A. Place a 4x4 wick in the stoma opening
• B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
• C. Cut the bag opening to the measurement of the stoma size
• D. Administer a PRN antidiarrheal agent

Correct answer: C

Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.

4. A client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?

• A. The neck extended backward using a rolled towel behind the neck
• B. Prone position using pillows to support both arms outward from the torso
• C. Side-lying position using pillows to support the abdomen and back
• D. The neck forward using pillows under the head and sandbags on both sides

Correct answer: D

Rationale: After sustaining burns to the face and neck, positioning is crucial to maintain functional posture, reduce pain, and prevent contractures. Placing the neck forward using pillows under the head and sandbags on both sides is the best option in this scenario. This position helps prevent neck and facial contractures, allowing for optimal function and healing. Choices A, B, and C do not adequately address the specific needs of a client with burns to the face and neck. Choice A could potentially exacerbate neck contractures, Choice B focuses on arm support rather than neck and face positioning, and Choice C does not directly address the needs of the burned face and neck, making them less effective in preventing contractures in these critical areas.

5. A client with a history of asthma is experiencing wheezing and shortness of breath. What is the priority nursing intervention?

• A. Administer a bronchodilator as prescribed
• B. Encourage the client to drink fluids
• C. Place the client in an upright position
• D. Assess the client's peak flow rate

Correct answer: A

Rationale: Administering a bronchodilator as prescribed is the priority nursing intervention for a client experiencing wheezing and shortness of breath due to asthma. Bronchodilators help relieve bronchoconstriction, allowing better airflow and improving breathing. Encouraging the client to drink fluids may be beneficial in certain situations, but it is not the priority when the client is in respiratory distress. Placing the client in an upright position, not supine, can facilitate easier breathing by allowing the chest to expand fully. While assessing the client's peak flow rate is important in asthma management, in this acute situation, the priority is to provide immediate relief by administering the bronchodilator.

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