Nursing Elites

1. A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?

• A. Monitor the site for further complications.
• B. Promptly remove the catheter from the radial artery.
• C. Elevate the client’s arm above the heart.
• D. Notify the healthcare provider and prepare for surgery.

Correct answer: B

Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.

2. A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is

• A. I must document and report any information.
• B. I can't make such a promise.
• C. That depends on what you tell me.
• D. I must report everything to the treatment team.

Correct answer: B

Rationale: The correct answer is B because the nurse cannot promise confidentiality in this context. It is essential to prioritize the safety and well-being of the client and others. Certain information, such as harm to oneself or others, must be reported to ensure appropriate interventions are taken. Choice A is incorrect because while documentation is important, confidentiality cannot be guaranteed in this situation. Choice C is incorrect as the nurse should not make promises that may conflict with their professional responsibilities. Choice D is incorrect as reporting everything to the treatment team without discretion may breach client confidentiality.

3. A client with lupus erythematosus is prescribed prednisone. What teaching should the nurse include?

• A. Take the medication with food to prevent stomach upset.
• B. Avoid crowded places to reduce the risk of infection.
• C. Take the medication in the morning to prevent insomnia.
• D. Take extra calcium supplements to prevent osteoporosis.

Correct answer: B

Rationale: The correct teaching for a client with lupus erythematosus prescribed prednisone is to avoid crowded places to reduce the risk of infection. Prednisone suppresses the immune system, making individuals more susceptible to infections. Taking the medication with food may help reduce stomach upset but is not the priority teaching. Taking prednisone in the morning may help reduce insomnia, but infection prevention is more critical. While prednisone can lead to osteoporosis, advising extra calcium supplements is not the most immediate concern when starting the medication.

4. The nurse reviews the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client support the diagnosis of tuberculosis?

• A. Mucopurulent cough and night sweats
• B. Fatigue and headache
• C. Persistent cough and weight gain
• D. Weight loss and fever

Correct answer: A

Rationale: A mucopurulent cough and night sweats are hallmark signs of active tuberculosis. These symptoms are key indicators of TB as the combination of a productive cough with night sweats is highly suggestive of the disease. Fatigue and headache (choice B) are nonspecific symptoms that can occur in many conditions and are not specific to TB. Persistent cough and weight gain (choice C) are not typical findings in tuberculosis. Weight loss and fever (choice D) can be present in TB, but the specific combination of mucopurulent cough and night sweats is more specific to the diagnosis.

5. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?

• A. Social isolation related to hearing loss
• B. Risk for injury related to vertigo
• C. Impaired verbal communication
• D. Impaired hearing related to ear disease

Correct answer: B

Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.

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