Nursing Elites

1. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and that the reading needs to be verified by another nurse.
• B. Contact the healthcare provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.

2. The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?

• A. Administration of plasma expanders
• B. Use of careful handwashing technique
• C. Application of a topical antibacterial cream
• D. Limiting visitors to the client with burns

Correct answer: B

Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections. Handwashing helps remove pathogens that could lead to infections, making it essential in the care of clients with burns.

3. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.

4. Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client’s plan of care?

• A. Recent serum hemoglobin level of 16 g/dL
• B. Opioid analgesic received one hour ago
• C. Stooped posture with an unsteady gait
• D. Expressed feelings of depression

Correct answer: B

Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

5. The nurse is completing a client's preoperative routine and finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

• A. Witness the client's signature on the permit.
• B. Answer the client's questions about the surgery.
• C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
• D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Correct answer: C

Rationale: The nurse should inform the surgeon immediately that the operative permit is not signed and that the client has questions about the surgery. It is crucial for the surgeon to be aware of the situation so they can address the client's concerns, explain the procedure, and obtain the necessary signed permit before proceeding with the surgery. This ensures informed consent and compliance with preoperative protocols.

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