Nursing Elites

1. What is the main characteristic of cystic fibrosis?

• A. Multiple upper respiratory infections
• B. An underproduction of exocrine glands
• C. Excessive, thick mucus
• D. An overproduction of thin mucus

Correct answer: C

Rationale: The main characteristic of cystic fibrosis is the production of excessive, thick mucus. This thick mucus leads to blockages in the airways, digestive system, and other organs. Choice A is incorrect because while individuals with cystic fibrosis are more prone to respiratory infections, the main characteristic is the mucus production. Choice B is incorrect as cystic fibrosis is characterized by the overproduction, not underproduction, of exocrine glands. Choice D is also incorrect as the mucus produced in cystic fibrosis is thick, not thin.

2. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?

• A. Hypotension
• B. Tachycardia
• C. Severe headache
• D. Flushed skin below the level of injury

Correct answer: C

Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.

3. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?

• A. No. When the lesions have disappeared, you may stop the nystatin.
• B. Yes. You should continue it for the full 7 days.
• C. No. Thrush is a self-limiting disorder, and nystatin is given for complete treatment.
• D. Yes. The medication should be refilled for a second week of therapy.

Correct answer: B

Rationale: The correct answer is B because nystatin should be given for the full 7 days even if the lesions are no longer present. Continuing the treatment for the prescribed duration ensures complete eradication of the fungal infection. Choice A is incorrect as stopping the medication prematurely may lead to the reoccurrence of thrush. Choice C is inaccurate as nystatin is not just for comfort but for effective treatment. Choice D is incorrect as refilling the medication for a second week without medical advice may lead to unnecessary prolonged use and potential side effects.

4. Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?

• A. Encourage the client to use an abductor pillow when ambulating.
• B. Teach the client to perform leg exercises in bed.
• C. Assist the client to sit at the edge of the bed.
• D. Assist the client to turn while an abductor pillow is between the legs.

Correct answer: D

Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.

5. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?

• A. Administer a prescribed sedative
• B. Encourage client to drink water
• C. Apply a high flow venturi mask
• D. Assist her to an upright position

Correct answer: D

Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.

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