Nursing Elites

1. Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?

• A. Risk for aspiration
• B. Impaired physical mobility
• C. Disturbed sensory perception
• D. Interrupted family processes

Correct answer: A

Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.

2. A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?

• A. Clean sutures along the incision site.
• B. Remove sutures using sterile technique.
• C. Inspect the wound for signs of infection.
• D. Document the removal of sutures.

Correct answer: B

Rationale: After applying sterile gloves, the nurse should proceed to remove the sutures using sterile technique. This step ensures the safe and effective removal of sutures without introducing infection. Choice A, cleaning sutures along the incision site, would not be the next step as the primary focus is on suture removal. Inspecting the wound for signs of infection (Choice C) is important but typically follows suture removal. Documenting the removal of sutures (Choice D) is essential but usually occurs after the procedure is completed.

3. When assessing readiness to learn about insulin self-administration, what indicates the client is ready to learn?

• A. I can concentrate best in the morning.
• B. I feel anxious about learning the process.
• C. I have a lot of questions about insulin.
• D. I am not sure if I can manage this at home.

Correct answer: A

Rationale: The correct answer is A: 'I can concentrate best in the morning.' Readiness to learn is indicated by the client's ability to focus and concentrate, as mentioned in the question. Choice B, 'I feel anxious about learning the process,' indicates apprehension and may hinder the learning process. Choice C, 'I have a lot of questions about insulin,' shows interest but does not directly indicate readiness to learn. Choice D, 'I am not sure if I can manage this at home,' reflects uncertainty and lack of confidence, which may suggest the client is not fully prepared to learn.

4. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

• A. Educating clients about the recommended immunization schedule for adults
• B. Teaching clients how to manage chronic illnesses
• C. Providing counseling for depression
• D. Offering support groups for cancer survivors

Correct answer: A

Rationale: The correct answer is A: Educating clients about the recommended immunization schedule for adults. This activity falls under primary prevention, which aims to prevent the onset of illness or injury. Immunizations are a proactive measure to protect individuals from developing certain diseases. Choices B, C, and D involve managing chronic illnesses, providing counseling for mental health issues, and offering support for individuals who have already experienced cancer, respectively. These activities are more aligned with secondary or tertiary prevention, focusing on managing existing conditions or preventing complications in those already affected.

5. A client with a prescription for a clear liquid diet is receiving teaching about food choices from a nurse. Which of the following selections by the client indicates an understanding of the teaching?

• A. Gelatin
• B. Whole milk
• C. Cream soups
• D. Orange juice

Correct answer: A

Rationale: The correct answer is A: Gelatin. Gelatin is suitable for a clear liquid diet because it is transparent and free of solid particles. Clear liquid diets are designed to be easily digested and leave minimal residue in the gastrointestinal tract. Choices B, C, and D are not appropriate for a clear liquid diet. Whole milk, cream soups, and orange juice contain solid particles or pulp, which are not allowed on a clear liquid diet. Whole milk and cream soups are not clear liquids as they contain milk solids and vegetable particles respectively. Orange juice contains pulp, which is not part of a clear liquid diet. It is important for clients to follow dietary restrictions to achieve the intended therapeutic outcomes.

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