Nursing Elites

1. 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.

2. A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?

• A. Glasgow Coma Scale (GCS) score of 15.
• B. Pupils are equal and reactive to light.
• C. Client is drowsy but arousable.
• D. Client does not remember the events leading to the injury.

Correct answer: C

Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.

3. The nurse is teaching a group of new mothers about infant care. Which topic should the nurse prioritize?

• A. signs of infant dehydration
• B. proper diaper changing techniques
• C. immunization schedule
• D. breastfeeding positions

Correct answer: A

Rationale: The correct answer is A: signs of infant dehydration. Recognizing signs of dehydration is crucial for ensuring the health and well-being of infants. Dehydration can be life-threatening for infants if not addressed promptly. While proper diaper changing techniques, immunization schedules, and breastfeeding positions are also important topics in infant care, being able to identify signs of dehydration takes precedence as it requires immediate attention to prevent serious consequences.

4. The school nurse is developing an individualized healthcare plan for a student with type 1 diabetes. Which component is most important to include in the plan?

• A. a schedule for blood glucose monitoring
• B. a list of low-carbohydrate snacks
• C. a contact list of healthcare providers
• D. a log for recording insulin administration

Correct answer: A

Rationale: The correct answer is A: a schedule for blood glucose monitoring. Regular blood glucose monitoring is essential in managing type 1 diabetes as it helps in monitoring blood sugar levels, adjusting treatment plans, and preventing complications such as hypoglycemia or hyperglycemia. Choice B, a list of low-carbohydrate snacks, while important for managing blood sugar levels, is not as critical as consistent blood glucose monitoring. Choice C, a contact list of healthcare providers, though important for emergency situations, is not the most crucial component in managing daily care. Choice D, a log for recording insulin administration, is valuable for tracking insulin doses but does not directly address the immediate need for monitoring blood glucose levels.

5. A community health nurse is helping a group of nursing students plan a tertiary prevention program for a local community clinic that serves a majority Hispanic population. Which service project meets the requirement of a tertiary prevention program and would best serve this population?

• A. teaching clients about recommended immunizations for children
• B. demonstrating foot care to a group of clients who have diabetes
• C. taking blood pressures at a local shopping mall in the community
• D. instructing teens about prevention of sexually transmitted diseases

Correct answer: B

Rationale: The correct answer is B. Tertiary prevention focuses on managing and improving health outcomes for existing conditions, such as diabetes. Demonstrating foot care to clients with diabetes aligns with this level of prevention by helping to prevent complications and promote better health outcomes. Choices A, C, and D do not specifically target existing conditions or chronic diseases, which are the focus of tertiary prevention programs.

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