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. An older client who had a subtotal parathyroidectomy is preparing for discharge. What finding requires immediate provider notification?

• A. Afebrile with a normal pulse.
• B. No bowel movement since surgery.
• C. No appetite for breakfast.
• D. A positive Chvostek's sign.

Correct answer: D

Rationale: A positive Chvostek's sign indicates hypocalcemia, a complication after parathyroid surgery that requires immediate attention. This sign is manifested by facial muscle twitching when the facial nerve in front of the ear is tapped, indicating neuromuscular irritability due to low calcium levels. Afebrile with a normal pulse (Choice A) is a normal finding and does not require immediate notification. No bowel movement since surgery (Choice B) is common postoperatively due to anesthesia effects and pain medications and usually resolves within a few days; it does not require immediate notification unless accompanied by other concerning symptoms. No appetite for breakfast (Choice C) is a common postoperative finding and does not require immediate notification unless it persists and leads to dehydration or malnutrition.

3. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote oxygenation by improving lung expansion
• C. To encourage use of accessory muscles for breathing
• D. To drain secretions and prevent aspiration

Correct answer: D

Rationale: Elevating the head of the bed in a client with acute respiratory distress syndrome (ARDS) is essential to drain secretions and prevent aspiration. This position helps facilitate the removal of secretions from the airways, reducing the risk of aspiration pneumonia. Choices A, B, and C are incorrect as the primary reason for elevating the head of the bed in ARDS is to assist with secretion drainage and prevent complications associated with aspiration.

4. The nurse is caring for a client with chronic renal failure who is receiving dialysis. The client reports muscle cramps and tingling in the hands. Which laboratory result should the nurse monitor to identify the cause of these symptoms?

• A. Sodium
• B. Calcium
• C. Phosphate
• D. Potassium

Correct answer: B

Rationale: Muscle cramps and tingling in clients with chronic renal failure are often associated with hypocalcemia. Monitoring calcium levels is crucial to identify imbalances and manage symptoms appropriately. Sodium, phosphate, and potassium levels are important in renal failure but are not directly related to the symptoms of muscle cramps and tingling reported by the client.

5. An unlicensed assistive personnel (UAP), who usually works on a surgical unit, is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?

• A. How long have you been a UAP and what units have you worked on?
• B. What type of care do you provide on the surgical unit, and what are the ages of the clients?
• C. What is your comfort level in caring for children and at what ages?
• D. Have you reviewed the list of expected skills you might need on this unit?

Correct answer: D

Rationale: The most appropriate question by the charge nurse would be to ask the UAP if they have reviewed the list of expected skills needed on the pediatric unit. This ensures that the UAP is aware of the specific skills required for safe and appropriate care in that particular unit. Choices A, B, and C do not directly address the need for the UAP to review the expected skills, which is crucial for delegation decisions during floating assignments.

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