Nursing Elites

1. A client who had a stroke is complaining of left-side weakness. What should the nurse prioritize?

• A. Initiate physical therapy immediately.
• B. Contact the physical therapy team.
• C. Reassess the client after administering pain medication.
• D. Start treatment immediately without consulting anyone.

Correct answer: B

Rationale: The correct answer is to contact the physical therapy team. When a client who had a stroke presents with left-side weakness, the nurse should prioritize coordinating with the physical therapy team rather than immediately initiating physical therapy. The initial step should involve assessing the client's condition and involving the appropriate healthcare team for a comprehensive care plan. Administering pain medication or starting treatment without consulting others can delay or hinder the appropriate care needed for the client's recovery.

2. What is the primary goal when caring for a patient with chronic obstructive pulmonary disease (COPD)?

• A. Maintain the patient's oxygen saturation above 90%.
• B. Administer bronchodilators as prescribed.
• C. Improve the patient's nutritional intake.
• D. Encourage the patient to limit physical activity.

Correct answer: A

Rationale: The correct answer is to maintain the patient's oxygen saturation above 90% when caring for a patient with COPD. In COPD, impaired gas exchange leads to decreased oxygen levels in the blood. By ensuring oxygen saturation remains above 90%, healthcare providers can prevent hypoxia and its complications. Administering bronchodilators as prescribed (Choice B) is an important intervention in managing COPD symptoms, but it is not the primary goal. Improving the patient's nutritional intake (Choice C) and encouraging the patient to limit physical activity (Choice D) are also essential aspects of COPD management, but they are not the primary goal when caring for a patient with this condition.

3. What should be done to ensure safety during the transfer of a patient with limited mobility?

• A. Have the patient use a gait belt for support.
• B. Encourage the patient to hold onto a walker.
• C. Lock the wheels on the bed and wheelchair.
• D. Ask the patient to transfer independently.

Correct answer: C

Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.

4. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

• A. Measure and document the urine in the drainage bag
• B. Remove the tape or device securing the catheter to the client's thigh
• C. Position the client supine
• D. Deflate the catheter balloon using a sterile syringe

Correct answer: A

Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.

5. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing an acute hemolytic reaction?

• A. Low back pain
• B. Distended neck veins
• C. Chills and fever
• D. Headache

Correct answer: C

Rationale: Chills and fever are classic signs of an acute hemolytic reaction, where the body is reacting to the transfused blood. This reaction can be life-threatening and requires immediate intervention. Low back pain, distended neck veins, and headache are not typical signs of an acute hemolytic reaction. Low back pain may be associated with kidney issues, distended neck veins with fluid overload or heart failure, and headache with various causes such as stress, dehydration, or migraines.

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