Nursing Elites

1. The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide?

• A. Invite friends over regularly to share meal times
• B. Encourage the client to drink clear liquids between meals
• C. Coach the client to make an intentional effort to swallow
• D. Talk to the healthcare provider about prescribing an appetite stimulant

Correct answer: A

Rationale: The best teaching for the nurse to provide is to invite friends over regularly to share meal times. This can help in making meal times more enjoyable for the client with Parkinson's disease, potentially encouraging him to eat more. Encouraging clear liquids between meals (choice B) may not address the underlying issue of weight loss. Coaching the client to make an intentional effort to swallow (choice C) may not be effective if the weight loss is due to other factors related to Parkinson's disease. While prescribing an appetite stimulant (choice D) could be an option, it is usually recommended to explore non-pharmacological interventions first, making choice A the most appropriate initial teaching intervention.

2. Following surgical repair of a cleft palate, what should be used to prevent injury to the suture line?

• A. Straw
• B. Spoon
• C. Syringe
• D. Cup

Correct answer: D

Rationale: Following surgical repair of a cleft palate, a cup should be used to prevent injury to the suture line. Utensils such as straws, spoons, droppers, and syringes should be avoided as they can cause trauma to the surgical site. Using a cup reduces the risk of disrupting the sutures and promotes proper healing.

3. The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?

• A. Check the BP every five minutes for one hour.
• B. Raise the HOB 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Take the client’s temperature using another method.

Correct answer: D

Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.

4. Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?

• A. Compare the client’s pain scale rating with the prescribed dosing.
• B. Determine which prescription will have the quickest onset of action.
• C. Ask the client to choose which medication is needed for the pain.
• D. Document the client’s report of pain in the electronic medical record.

Correct answer: A

Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client’s pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.

5. What is the most common clinical manifestation of coarctation of the aorta?

• A. Clubbing of the digits
• B. Upper extremity hypertension
• C. Pedal edema and portal congestion
• D. Loud systolic ejection murmur

Correct answer: B

Rationale: The correct answer is B: Upper extremity hypertension. Coarctation of the aorta leads to increased blood pressure in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs. Choice A, clubbing of the digits, is not a common clinical manifestation of coarctation of the aorta. Choice C, pedal edema, and portal congestion are more suggestive of conditions like heart failure rather than coarctation of the aorta. Choice D, loud systolic ejection murmur, can be heard in conditions like aortic stenosis, but it is not the most common clinical manifestation of coarctation of the aorta.

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