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 presents to the emergency room with an acute asthma attack. What is the nurse's priority intervention?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen at 2 liters per nasal cannula.
• C. Perform chest physiotherapy.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as prescribed. During an acute asthma attack, the priority is to open the airways quickly to help the client breathe more easily. Oxygen may be needed but bronchodilators take precedence as they directly target bronchoconstriction. Chest physiotherapy is not indicated in the acute phase of asthma and may exacerbate the condition. While emotional support is important, addressing the airway obstruction takes precedence in this situation.

3. The nurse is conducting diet teaching for a client diagnosed with hypertension. Which foods should the nurse encourage the client to eat?

• A. Pickled olives
• B. Canned soup
• C. Fresh or frozen vegetables without sauce
• D. Fruits without sauce

Correct answer: C

Rationale: The correct answer is C: Fresh or frozen vegetables without sauce. These foods are low in sodium, which is crucial for managing hypertension. Pickled olives (choice A) and canned soup (choice B) are high in sodium, which can exacerbate hypertension. While fruits without sauce (choice D) are generally healthy, emphasizing vegetables is more beneficial for hypertension due to their lower sodium content.

4. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?

• A. To observe the type and amount of nasogastric tube drainage
• B. Monitor the client for nausea or other complications
• C. Irrigate the nasogastric tube with the ordered irrigation solution
• D. Perform nostril and mouth care

Correct answer: D

Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.

5. The healthcare worker is wearing PPE while caring for a client. When exiting the room, which PPE should be removed first?

• A. Gloves
• B. Face shield
• C. Mask
• D. Gown

Correct answer: A

Rationale: Gloves should be removed first as they are most likely to be contaminated. This is followed by the gown, then face shield, and mask. Correct removal sequence helps prevent contamination. Removing gloves first reduces the risk of transferring pathogens from the gloves to other PPE or surfaces. Face shield and mask should be removed last as they protect mucous membranes from exposure to contaminants. Removing PPE in the correct sequence is crucial in preventing the spread of infections.

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