Nursing Elites

1. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

2. What information should the nurse include in the teaching plan of a client diagnosed with GERD?

• A. Sleep without using pillows
• B. Opt for five small meals throughout the day instead of three full meals with no snacks
• C. Minimize symptoms by wearing loose, comfortable clothing
• D. Engage in low-impact exercises like walking or swimming

Correct answer: C

Rationale: The correct answer is C: 'Minimize symptoms by wearing loose, comfortable clothing.' Wearing loose, comfortable clothing can help reduce pressure on the abdomen, which can alleviate GERD symptoms. Option A is incorrect as sleeping without using pillows is not a recommended practice for managing GERD. Option B is incorrect because it suggests adjusting food intake to five small meals throughout the day instead of three full meals with no snacks, which may not be suitable for everyone with GERD. Option D is incorrect as avoiding participation in any aerobic exercise program is not a standard recommendation for managing GERD; in fact, engaging in low-impact exercises like walking or swimming can be beneficial.

3. A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity
• B. Fluid volume deficit
• C. Imbalanced nutrition: less than body requirements
• D. Activity intolerance

Correct answer: B

Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.

4. The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?

• A. Liver.
• B. Oranges.
• C. Leafy green vegetables.
• D. Kidney beans.

Correct answer: B

Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.

5. Which statement correctly explains the etiology of Down syndrome?

• A. There is an extra chromosome on the 21st pair.
• B. There is a missing chromosome on the 21st pair.
• C. There are two pairs of the 21st chromosome.
• D. The 21st chromosome pair is missing.

Correct answer: A

Rationale: The correct answer is A: 'There is an extra chromosome on the 21st pair.' Down syndrome is caused by the presence of an extra copy of chromosome 21, known as trisomy 21. This additional genetic material leads to the characteristics associated with Down syndrome. Choices B, C, and D are incorrect because Down syndrome is not due to a missing chromosome or having two pairs of the 21st chromosome; it results from the presence of an extra chromosome on the 21st pair.

Similar Questions