Nursing Elites

1. When a client is suspected of having a stroke, what is the nurse's priority action?

• A. Administer tissue plasminogen activator (tPA).
• B. Perform a neurological assessment.
• C. Position the client in a supine position.
• D. Check the client's blood glucose level.

Correct answer: B

Rationale: The correct answer is to perform a neurological assessment. When a stroke is suspected, the priority action is to assess the client neurologically to determine the extent of brain injury and identify any immediate risks, such as impaired airway, speech deficits, or loss of motor function. This assessment helps in early recognition of signs that are essential for timely intervention and guides further treatment, such as administering tissue plasminogen activator (tPA), if appropriate. Positioning the client in a supine position or checking the blood glucose level can be important but not the priority when a stroke is suspected.

2. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

3. A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?

• A. Limit sodium intake to 2 grams per day.
• B. Choose fresh fruits and vegetables.
• C. Drink at least 8 glasses of water daily.
• D. Avoid processed foods and canned soups.

Correct answer: D

Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.

4. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

5. Which statement made by the client indicates an understanding of the instructions regarding the administration of alendronate (Fosamax)?

• A. I will take the medication at bedtime to avoid stomach upset.
• B. I will take the medication with a full glass of water first thing in the morning.
• C. I will lie down for 30 minutes after taking the medication.
• D. I will take the medication with food to reduce stomach irritation.

Correct answer: B

Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.

Similar Questions