Nursing Elites

1. The nurse is providing discharge instructions to a client who has had a stroke. Which intervention should the nurse recommend to prevent aspiration during meals?

• A. Encourage the client to take large bites of food
• B. Advise the client to eat quickly to prevent fatigue
• C. Offer the client thin liquids with meals
• D. Instruct the client to sit upright while eating

Correct answer: D

Rationale: Instructing the client to sit upright while eating is crucial to prevent aspiration in stroke clients. This position helps in safe swallowing and reduces the risk of food or liquid entering the airway. Encouraging the client to take large bites of food (Choice A) can increase the risk of choking and aspiration. Advising the client to eat quickly (Choice B) may lead to fatigue and compromise safe swallowing. Offering thin liquids (Choice C) can also increase the risk of aspiration in stroke clients, as thicker liquids are usually recommended to prevent aspiration.

2. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?

• A. Decreased pain and increased redness around the ulcer.
• B. Increased serous drainage from the ulcer site.
• C. Cool extremities and weak peripheral pulses.
• D. Pitting edema around the ulcer site.

Correct answer: C

Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.

3. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

• A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
• B. Listen with the bell of the stethoscope at the same location
• C. Listen at a different location over the aortic area
• D. Switch to the apical area and reassess for S3 sounds

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

4. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?

• A. Potassium level of 4.0 mEq/L.
• B. Blood glucose level of 180 mg/dL.
• C. Urine output of 50 mL/hour.
• D. Absence of ketones in the urine.

Correct answer: D

Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.

5. An adolescent with intellectual disability is admitted for refusing to complete oral hygiene. A behavior modification program is recommended. Which reinforcement is best?

• A. Unit tasks for each omitted teeth brushing.
• B. Candy for each successfully completed hygiene task.
• C. Privilege restriction for refusing hygiene tasks.
• D. Preferred activities or tokens for compliance.

Correct answer: D

Rationale: The best reinforcement strategy in this scenario is providing preferred activities or tokens for compliance. Positive reinforcement is effective in behavior modification programs for individuals with intellectual disabilities. Offering preferred activities or tokens serves as a reward for completing the desired behavior, in this case, oral hygiene tasks. Choices A, B, and C do not focus on reinforcing the desired behavior with positive incentives. Choice A does not provide a positive reinforcement for compliance but rather focuses on the omission of a task. Choice B uses candy, which may not be ideal for oral hygiene. Choice C involves punishment rather than positive reinforcement.

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