Nursing Elites

1. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

2. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding would be most concerning?

• A. Peripheral edema
• B. Crackles in the lungs
• C. Jugular vein distention
• D. Hepatomegaly

Correct answer: B

Rationale: The correct answer is B: Crackles in the lungs. Crackles in the lungs indicate pulmonary congestion, a serious complication of left-sided heart failure. The presence of crackles suggests fluid accumulation in the lungs, impairing gas exchange and potentially leading to respiratory distress. Immediate intervention is necessary to prevent worsening respiratory function. Choices A, C, and D are incorrect: Peripheral edema is a common finding in heart failure but may not be as acutely concerning as pulmonary congestion. Jugular vein distention is associated with right-sided heart failure, not left-sided heart failure. Hepatomegaly is often seen in liver conditions and right-sided heart failure, not specifically left-sided heart failure.

3. A healthcare professional is preparing to administer IV fluids to a client. The professional notes sparks when plugging in the IV pump. Which of the following actions should the professional take first?

• A. Label the pump with a defective equipment sticker.
• B. Unplug the pump.
• C. Obtain a replacement pump.
• D. Notify the maintenance department to fix the pump.

Correct answer: B

Rationale: Unplugging the pump is the correct initial action in this situation to prevent any potential fire hazards. Sparks when plugging in the IV pump indicate an electrical issue that can lead to a fire. By immediately unplugging the pump, the healthcare professional ensures the safety of the client and prevents any further risks. Labeling the pump with a defective equipment sticker (Choice A) is not the priority as the immediate concern is safety. Obtaining a replacement pump (Choice C) can be considered after addressing the safety issue. Notifying the maintenance department (Choice D) is important but should follow the immediate action of unplugging the pump to mitigate the risk.

4. When demonstrating an empathic presence to a client, which of the following actions should the nurse take?

• A. Use an open posture
• B. Write down what the client says for accurate documentation
• C. Establish and maintain eye contact
• D. Nod in agreement with the client throughout the conversation

Correct answer: A

Rationale: Using an open posture is crucial when demonstrating empathy to a client. This body language conveys openness, understanding, and a willingness to listen, creating a safe space for the client to express themselves. Establishing and maintaining eye contact is also important as it fosters a sense of connection and validation for the client. Writing down what the client says is essential for accurate documentation and memory but does not directly contribute to demonstrating empathic presence. Nodding in agreement with the client throughout the conversation may show attentiveness, but it does not necessarily reflect empathy or active listening as it could be misinterpreted as simply agreeing with what is being said.

5. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

• A. Perform hand hygiene
• B. Identify the client using two identifiers
• C. Prepare the sterile field
• D. Don sterile gloves

Correct answer: A

Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.

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