Nursing Elites

1. What is the function of the epiglottis during swallowing?

• A. Prevents food from entering the trachea
• B. Aids in food propulsion
• C. Enhances taste sensation
• D. Lubricates the esophagus

Correct answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

2. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?

• A. Apply heat to the residual limb.
• B. Administer prescribed analgesics.
• C. Elevate the residual limb.
• D. Perform range-of-motion exercises.

Correct answer: B

Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.

3. A client is post-operative day one following a colostomy surgery. The nurse notices the stoma is dark purple. What is the most appropriate action?

• A. Document the finding and continue to monitor.
• B. Apply warm compresses to the stoma.
• C. Notify the healthcare provider immediately.
• D. Encourage the client to ambulate.

Correct answer: C

Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.

4. An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the nurse document as evidence that the amount of insulin is inadequate?

• A. States that her feet are constantly cold and numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dL
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: The correct answer is C. Consistently high evening glucose levels indicate that the current insulin dosage is inadequate to maintain proper glucose control. Choice A is incorrect because cold and numb feet are more indicative of peripheral vascular disease rather than inadequate insulin dosage. Choice B describes a wound that may be related to poor circulation or neuropathy but not necessarily inadequate insulin dosage. Choice D suggests gastrointestinal issues that are not directly related to insulin dosage adequacy.

5. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the PN?

• A. No bowel movement for two days
• B. Mother assists child in changing positions
• C. Weights are touching the foot of the bed
• D. Child is able to move the toes freely when tickled

Correct answer: C

Rationale: In 90-90 traction, it is crucial to ensure that the weights are not touching the foot of the bed as this can disrupt the effective application of traction. This interference can hinder the proper alignment of the fractured femur and impede the healing process. Therefore, this finding requires immediate action to prevent complications. Choices A, B, and D are not directly related to the proper application of traction and do not pose a risk to the patient's treatment or well-being. No bowel movement for two days may indicate constipation but does not directly relate to the traction. Mother assisting the child in changing positions is a supportive action. The child being able to move the toes freely when tickled indicates neurological function, which is a positive sign.

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