Nursing Elites

1. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, what substance should the nurse suggest the parents give the child sips of?

• A. Tea
• B. Water
• C. Milk
• D. Soda

Correct answer: B

Rationale: The correct answer is B: Water. Giving sips of water can help dilute the drain cleaner while waiting for emergency transport, which may help reduce the potential harm caused by the ingestion. Choices A, C, and D are incorrect because tea, milk, and soda can interact with the chemicals in the drain cleaner or increase the risk of vomiting, which is not recommended in this situation.

2. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is 'D: I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or any other medications that can increase the risk of bleeding without consulting their healthcare provider. Choices A, B, and C are correct statements that demonstrate understanding of warfarin therapy and its potential side effects. Avoiding foods high in vitamin K helps maintain the effectiveness of warfarin, taking medication at the same time every day ensures consistent therapeutic levels, and using a soft toothbrush helps prevent gum bleeding, which can be a side effect of warfarin therapy.

3. A client has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?

• A. Ankle-foot orthotic
• B. Continuous passive motion machine
• C. Abduction splint
• D. Sequential compression device

Correct answer: A

Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.

4. A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client’s plan of care?

• A. Schedule rest periods during morning care.
• B. Discontinue morning care for 2 days.
• C. Perform all care as quickly as possible.
• D. Ask a family member to come in to bathe the client.

Correct answer: A

Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.

5. A client has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

• A. This type of hearing aid allows for fine-tuning of volume.
• B. I should ensure the hearing aid stays secure during exercise.
• C. I might hear a whistling sound when I first insert the hearing aid.
• D. I will be sure to remove my hearing aid before taking a shower.

Correct answer: D

Rationale: The correct answer is D because removing the hearing aid before taking a shower is essential to prevent water damage, as moisture can harm the device. Choice A is incorrect because behind-the-ear hearing aids do allow for fine-tuning of volume. Choice B is incorrect because exercise may cause the hearing aid to shift position, so it's important to ensure it stays secure. Choice C is incorrect because hearing a whistling sound when inserting the hearing aid may indicate improper placement or fit.

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