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. A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?

• A. Monitor for signs of a pulmonary embolism.
• B. Assess for signs of dehydration.
• C. Monitor for signs of compartment syndrome.
• D. Check the client’s oxygen saturation levels.

Correct answer: A

Rationale: The correct answer is A. Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention. Pulmonary embolism occurs when a blood clot travels to the lungs, potentially blocking blood flow and leading to serious complications. Choices B, C, and D are incorrect because dehydration, compartment syndrome, and oxygen saturation levels are not typically associated with unilateral leg swelling after a long flight. While dehydration can cause leg cramps, compartment syndrome is more commonly associated with trauma or injury, and oxygen saturation levels are not the primary concern in this scenario.

3. When speaking with a group of teens about chemotherapy side effects for cancer, which side effect would the nurse expect this group to be more interested in discussing?

• A. Mouth sores
• B. Fatigue
• C. Diarrhea
• D. Hair loss

Correct answer: D

Rationale: Teens are more likely to be concerned with hair loss when discussing chemotherapy side effects because it is a visible and emotionally impactful side effect for them. While all the listed side effects are important to consider, hair loss can have a significant impact on a teenager's self-image and emotional well-being, making it a key point of interest for this age group. Mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, but they may not carry the same level of emotional weight and visibility as hair loss for teens.

4. Before a client with renal failure undergoes hemodialysis, what should the nurse assess?

• A. Check the client's potassium levels
• B. Review the client's medication list
• C. Assess the client's peripheral pulses
• D. Monitor the client's urine output

Correct answer: A

Rationale: The correct answer is to check the client's potassium levels. Potassium levels are crucial to assess before hemodialysis in a client with renal failure because hyperkalemia (high potassium) is a common complication in these patients. Hemodialysis aims to remove excess potassium from the blood, making it essential to monitor potassium levels to determine the need for appropriate interventions. Reviewing the client's medication list (Choice B) is important for overall care but is not as directly relevant to the immediate concerns before hemodialysis. Assessing peripheral pulses (Choice C) and monitoring urine output (Choice D) are important aspects of nursing assessment but are not as directly related to the specific preparation needed before hemodialysis in a client with renal failure.

5. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

• A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
• B. Listen with the bell of the stethoscope at the same location
• C. Listen at a different location over the aortic area
• D. Switch to the apical area and reassess for S3 sounds

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

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