Nursing Elites

1. In conducting a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?

• A. a 45-year-old father who smokes and has high cholesterol
• B. a 17-year-old daughter who is overweight and inactive
• C. a 50-year-old mother with a history of hypertension
• D. a 12-year-old son who has a normal weight and is active

Correct answer: A

Rationale: The 45-year-old father who smokes and has high cholesterol is at a higher risk for cardiovascular disease due to multiple risk factors. Smoking and high cholesterol are significant contributors to the development of cardiovascular issues. Prioritizing his evaluation and intervention is crucial to address these modifiable risk factors. The other family members, though they may have risk factors as well, do not present with the same level of immediate risk based on the information provided.

2. The nurse is preparing to administer an oral medication to a client with dysphagia. Which action should the nurse take?

• A. Crush the medication and mix it with applesauce.
• B. Have the client drink a full glass of water with the medication.
• C. Administer the medication with a small amount of pudding.
• D. Place the medication at the back of the client's tongue.

Correct answer: C

Rationale: The correct action for the nurse to take when administering oral medication to a client with dysphagia is to administer the medication with a small amount of pudding. This method helps prevent aspiration in clients with dysphagia by ensuring easier swallowing. Crushing the medication and mixing it with applesauce (Choice A) might alter the medication's efficacy. Having the client drink a full glass of water with the medication (Choice B) may not be suitable for a client with dysphagia as it can increase the risk of aspiration. Placing the medication at the back of the client's tongue (Choice D) can also lead to aspiration and is not recommended.

3. The healthcare provider is preparing to administer an intravenous (IV) medication to a client. Which action should the healthcare provider take first?

• A. Verify the client's identity using two identifiers.
• B. Check the client's allergy status.
• C. Prepare the medication for administration.
• D. Administer the medication at the prescribed rate.

Correct answer: B

Rationale: Checking the client's allergy status is the priority before administering any medication, especially intravenously. This step helps identify any potential allergic reactions and prevents harm to the client. Verifying the client's identity using two identifiers is important but not the first step in medication administration. Preparing the medication for administration and administering the medication at the prescribed rate come after ensuring the client's safety by checking for allergies.

4. The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?

• A. Lung sounds and respiratory status.
• B. Skin integrity and color.
• C. Neurological status and level of consciousness.
• D. Cardiac rate and rhythm.

Correct answer: D

Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.

5. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which finding indicates that the therapy is effective?

• A. The client is able to expectorate secretions easily.
• B. The client's oxygen saturation is 92%.
• C. The client's respiratory rate is 20 breaths per minute.
• D. The client's arterial blood gases show a pH of 7.35.

Correct answer: C

Rationale: In a client with COPD receiving oxygen therapy, an effective response is indicated by a respiratory rate of 20 breaths per minute. This suggests that the client is effectively oxygenating while maintaining an appropriate respiratory rate. Choices A, B, and D are incorrect because expectorating secretions easily, having an oxygen saturation of 92%, and arterial blood gases showing a pH of 7.35 are not specific indicators of the effectiveness of oxygen therapy in COPD. Oxygen saturation of 92% may still be suboptimal in COPD, and arterial blood gases showing a pH of 7.35 may not necessarily reflect the overall effectiveness of oxygen therapy.

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