Nursing Elites

1. A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

• A. Position the head of the bed (HOB) flat.
• B. Withhold intravenous fluids.
• C. Administer a bolus of IV fluids.
• D. Give an antihypertensive medication.

Correct answer: D

Rationale: In a client with a completed ischemic stroke, an elevated blood pressure like 180/90 mm Hg requires immediate intervention to prevent further damage. Giving an antihypertensive medication is essential to reduce the risk of recurrent stroke or complications related to hypertension. Positioning the head of the bed flat, withholding IV fluids, or administering a bolus of IV fluids are not appropriate actions for managing elevated blood pressure in this scenario and may not address the underlying cause of the hypertension or prevent potential complications.

2. The nurse is caring for a patient who has recurrent urinary tract infections. The patient’s current infection is not responding to an antibiotic that has been used successfully several times in the past. The nurse understands that this is most likely due to

• A. acquired bacterial resistance.
• B. cross-resistance.
• C. inherent bacterial resistance.
• D. transferred resistance.

Correct answer: A

Rationale: The correct answer is A: acquired bacterial resistance. Acquired resistance happens when an organism has been exposed to the antibacterial drug, making it less effective over time. Cross-resistance (B) occurs when resistance to one drug leads to resistance to another. Inherent resistance (C) happens without prior exposure to the drug, meaning the bacteria are naturally resistant. Transferred resistance (D) involves the transfer of resistant genes from one organism to another, contributing to resistance development.

3. A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?

• A. He visits his diabetic brother who just had surgery to amputate an infected foot.
• B. He is provided with the most current information about the dangers of untreated diabetes.
• C. He comments on the community service announcements about preventing complications associated with diabetes.
• D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.

Correct answer: A

Rationale: According to the Health Belief Model, the most effective event to increase compliance with the prescribed diet for a middle-aged male client with diabetes is experiencing a significant consequence related to the disease. In this case, visiting his diabetic brother who just had surgery to amputate an infected foot would serve as a strong 'cue to action,' increasing the client's perceived seriousness of the disease. This event is likely to have a more immediate and impactful effect on the client than other options. Option B provides valuable information but may not have the same personal and emotional impact as witnessing a severe consequence firsthand. Option C involves indirect exposure to prevention messages, which might not be as compelling as a direct experience. Option D, while supportive, does not present a direct consequence of non-compliance like option A does.

4. In a patient with chronic kidney disease, which of the following lab values would be expected?

• A. Elevated creatinine levels.
• B. Low hemoglobin levels.
• C. Elevated potassium levels.
• D. Low sodium levels.

Correct answer: A

Rationale: In chronic kidney disease, elevated creatinine levels are expected due to impaired kidney function. Creatinine is a waste product that is typically filtered out by the kidneys. With kidney disease, the clearance of creatinine is reduced, leading to its accumulation in the blood. Low hemoglobin levels (choice B) may be seen in chronic kidney disease due to decreased production of erythropoietin. However, elevated potassium levels (choice C) and low sodium levels (choice D) are more commonly associated with kidney dysfunction but are not as specific indicators of chronic kidney disease as elevated creatinine levels.

5. The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy?

• A. The biopsy will confirm the diagnosis of Hodgkin's disease.
• B. The biopsy will show the extent of the disease in the bones.
• C. The biopsy will be done to check for infection in the bones.
• D. The biopsy will help determine the best treatment for the disease.

Correct answer: D

Rationale: A bone marrow biopsy helps determine the best treatment plan for Hodgkin's disease by providing crucial information about the extent and nature of the disease. While confirming the diagnosis is important, the primary purpose of the biopsy in this case is to guide treatment decisions. The biopsy is not primarily for assessing the extent of the disease in the bones or checking for infections in the bones.

Similar Questions