Nursing Elites

1. What is the appropriate nursing intervention for a patient experiencing a suspected stroke?

• A. Administer thrombolytics
• B. Perform a neurological assessment
• C. Perform a CT scan
• D. Administer oxygen

Correct answer: B

Rationale: Performing a neurological assessment is the appropriate nursing intervention for a patient experiencing a suspected stroke. This assessment helps determine the severity of the stroke, identify potential deficits, and guide further interventions. Administering thrombolytics (Choice A) should only be done after a CT scan to confirm the type of stroke and rule out hemorrhagic stroke. Performing a CT scan (Choice C) is important but is typically done after stabilizing the patient. Administering oxygen (Choice D) is essential to maintain adequate oxygenation, but performing a neurological assessment takes precedence in the immediate management of a suspected stroke.

2. A client in active labor requests pain management. Which of the following actions should the nurse take?

• A. Administer ondansetron.
• B. Place the client in a warm shower.
• C. Apply fundal pressure during contractions.
• D. Assist the client to a supine position.

Correct answer: B

Rationale: During active labor, nonpharmacologic comfort measures like placing the client in a warm shower are effective for pain relief. Ondansetron (Choice A) is an antiemetic and not used for pain management during labor. Applying fundal pressure (Choice C) can cause harm and is not recommended due to the risk of uterine rupture. Assisting the client to a supine position (Choice D) is not ideal in labor as it can decrease blood flow to the placenta and is associated with increased maternal complications.

3. A nurse is providing discharge teaching to a client who is recovering from a myocardial infarction. Which of the following client statements indicates a need for further teaching?

• A. I will take a daily aspirin to prevent another heart attack.
• B. I should expect to experience chest pain when I exercise.
• C. I will increase my intake of saturated fats.
• D. I will participate in a cardiac rehabilitation program.

Correct answer: C

Rationale: The correct answer is C. Increasing the intake of saturated fats can raise cholesterol levels, which is not recommended after a myocardial infarction. Choices A, B, and D are all appropriate statements indicating a good understanding of post-myocardial infarction care. Taking a daily aspirin can help prevent another heart attack, experiencing chest pain with exercise is a common expectation post-myocardial infarction, and participating in a cardiac rehabilitation program is important for recovery and improving heart health.

4. A nurse is assessing a client who has gastroesophageal reflux disease (GERD). Which of the following findings should the nurse expect?

• A. Abdominal distention
• B. Burning sensation in the chest
• C. Constipation
• D. Frequent belching

Correct answer: B

Rationale: The correct answer is B: Burning sensation in the chest. A burning sensation in the chest is a classic symptom of gastroesophageal reflux disease (GERD). Abdominal distention (Choice A) is not typically associated with GERD; it is more commonly seen in conditions like bowel obstruction. Constipation (Choice C) is not a hallmark symptom of GERD, as it is more related to gastrointestinal motility issues. Frequent belching (Choice D) can occur with GERD, but it is not as specific or characteristic as the burning sensation in the chest.

5. A nurse is providing teaching to a client who is receiving radiation therapy for cancer of the larynx. Which of the following instructions should the nurse include?

• A. Apply heat to the neck to relieve pain.
• B. Use a soft-bristle toothbrush to prevent gum irritation.
• C. Rinse your mouth with an alcohol-free mouthwash twice daily.
• D. Wear loose-fitting clothing to protect your skin.

Correct answer: B

Rationale: The correct answer is to use a soft-bristle toothbrush to prevent gum irritation in clients undergoing radiation therapy for laryngeal cancer. Radiation therapy can cause oral mucositis and increase the risk of gum irritation, so using a soft-bristle toothbrush is recommended to minimize trauma to the gums and oral mucosa. Applying heat to the neck is contraindicated as it can exacerbate tissue damage caused by radiation. Rinsing the mouth with an alcohol-free mouthwash is preferred over an alcohol-based one to prevent drying and irritation of the oral mucosa. Wearing loose-fitting clothing is advised to prevent friction and irritation on the skin, rather than tight-fitting clothing that may cause pressure ulcers or skin breakdown.

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