Nursing Elites

1. The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement?

• A. Teach the client the use of basic sign language
• B. Speak slowly to the client
• C. Encourage the client's use of picture charts
• D. Ask the client simple questions

Correct answer: C

Rationale: Encouraging the client's use of picture charts is the most appropriate intervention for a client with expressive aphasia. Picture charts provide visual cues that can aid in communication and reduce frustration for the client. This intervention can help the client express their needs and thoughts effectively. Teaching sign language (Choice A) may be challenging and not as practical in this situation as it may not address the specific communication barriers caused by expressive aphasia. Speaking slowly (Choice B) may not fully address the communication difficulties associated with expressive aphasia. Asking simple questions (Choice D) may not be effective as the client may have difficulty understanding and responding due to the nature of expressive aphasia.

2. A client has been scheduled for magnetic resonance imaging (MRI). For which of the following conditions, a contraindication to MRI, does the nurse check the client’s medical history?

• A. Pancreatitis
• B. Pacemaker insertion
• C. Type 1 diabetes mellitus
• D. Chronic airway limitation

Correct answer: B

Rationale: The correct answer is B: Pacemaker insertion. Patients with metal devices or implants are contraindicated for MRI. These include pacemakers, orthopedic hardware, artificial heart valves, aneurysm clips, and intrauterine devices. These metal objects can be affected by the strong magnetic field of the MRI, leading to serious risks for the patient. Pancreatitis (choice A), Type 1 diabetes mellitus (choice C), and chronic airway limitation (choice D) are not contraindications to MRI based on the presence of metal objects. Therefore, the nurse should be particularly concerned about pacemaker insertion when reviewing the client's medical history prior to an MRI.

3. A client is vomiting. For which acid-base imbalance does the nurse assess the client?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: B

Rationale: In a client who is vomiting, the loss of gastric fluid containing hydrochloric acid can lead to metabolic alkalosis. Metabolic alkalosis is caused by the loss of acids such as hydrochloric acid from the body. Therefore, in this scenario, the nurse should assess the client for metabolic alkalosis. Choices A, C, and D are incorrect because vomiting does not typically lead to metabolic acidosis, respiratory acidosis, or respiratory alkalosis.

4. Which of the following is a common complication of immobility?

• A. Muscle hypertrophy.
• B. Pressure ulcers.
• C. Bone fractures.
• D. Joint stiffness.

Correct answer: B

Rationale: The correct answer is B, Pressure ulcers. Immobility can lead to pressure ulcers due to prolonged pressure on the skin, especially over bony prominences. Muscle hypertrophy (Choice A) is not a common complication of immobility; instead, muscle atrophy is more likely to occur due to disuse. Bone fractures (Choice C) can result from trauma but are not directly associated with immobility unless there is a fall or accident. Joint stiffness (Choice D) can develop due to lack of movement but is not as common or severe as pressure ulcers in cases of prolonged immobility.

5. Upon arrival of a client transferred to the surgical unit, what should the nurse plan to do first?

• A. Assess the patency of the airway
• B. Check tubes and drains for patency
• C. Check the dressing for bleeding
• D. Assess the vital signs to compare them with preoperative measurements

Correct answer: A

Rationale: The initial action for the nurse upon the arrival of a client to the surgical unit is to assess the patency of the airway. This step takes priority to ensure that the client has a clear airway for adequate breathing. Checking tubes and drains for patency, inspecting the dressing for bleeding, and assessing vital signs to compare with preoperative measurements are important subsequent steps in the assessment process. However, ensuring the airway is patent is the immediate priority to maintain the client's respiratory function and overall well-being.

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