Nursing Elites

1. Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?

• A. Prevent the spread of infection to others
• B. Improve the function of the immune system
• C. Increase the ability to carry out activities of daily living
• D. Promote a feeling of general well-being

Correct answer: B

Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.

2. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)

• A. Protect the medication from light exposure
• B. Monitor for changes in level of consciousness
• C. Observe for onset of generalized bruising or bleeding
• D. Perform ongoing assessment of respiratory status

Correct answer: D

Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.

3. A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?

• A. Cheddar cheese and crackers
• B. Carrot and celery sticks
• C. Beef bologna sausage slices
• D. Dry roasted almonds

Correct answer: D

Rationale: Dry roasted almonds are the most suitable snack option for a client with chronic alcoholism and a decreased serum magnesium level because they are high in magnesium. Magnesium is essential in addressing the deficiency. Cheddar cheese and crackers (Choice A) do not contain as much magnesium as almonds. Carrot and celery sticks (Choice B) are healthy choices but do not provide a significant amount of magnesium. Beef bologna sausage slices (Choice C) are not a good choice as processed meats are not rich in magnesium.

4. A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client’s plan of care?

• A. Encourage speaking slowly and articulating words
• B. Sit upright and flex chin forward while swallowing
• C. Position a communication board at the bedside
• D. Provide feeding utensils with large grip handles

Correct answer: B

Rationale: The correct intervention for a client with ALS experiencing difficulty swallowing and articulating words is to sit upright and flex the chin forward while swallowing. This position helps manage dysphagia associated with ALS by facilitating the swallowing process. Encouraging speaking slowly and articulating words (Choice A) may be helpful for speech clarity but does not address the swallowing issue. Positioning a communication board (Choice C) would not directly address the swallowing difficulty. Providing feeding utensils with large grip handles (Choice D) is not the priority intervention for managing dysphagia in ALS.

5. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?

• A. Administer regular insulin per sliding scale
• B. Cancel the client's dinner tray
• C. Give the client 4 ounces (120 mL) of orange juice
• D. Administer the next scheduled dose of metformin

Correct answer: A

Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.

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