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. After abdominal surgery, an adult is now alert and oriented. What position is most appropriate for the client?

• A. Semi-Fowler's
• B. Prone
• C. Supine
• D. Sim's

Correct answer: A

Rationale: The most appropriate position for a client following abdominal surgery is Semi-Fowler's. This position promotes greater thoracic expansion and reduces pressure on the suture line, aiding in respiratory function and preventing strain on the incision site. Choices B, C, and D are incorrect. Prone position (Choice B) would not be suitable after abdominal surgery as it can put pressure on the abdomen. Supine position (Choice C) may cause discomfort and strain on the incision area. Sim's position (Choice D) is primarily used for rectal exams and enemas, which are unrelated to the needs post-abdominal surgery.

3. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse.
• B. Encourage the client to get to the toilet.
• C. In a loud voice, call for help.
• D. Gently lower the client to the floor.

Correct answer: D

Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.

4. A client with frequent urinary tract infections (UTIs) asks the nurse about drinking juice daily to prevent future UTIs. Which response is best for the nurse to provide?

• A. Orange juice has vitamin C, which deters bacterial growth.
• B. Apple juice is the most useful in acidifying the urine.
• C. Cranberry juice stops pathogens' adherence to the bladder.
• D. Grapefruit juice increases the absorption of most antibiotics.

Correct answer: C

Rationale: Cranberry juice is known for its ability to prevent urinary tract infections by reducing the adherence of Escherichia coli bacteria to the cells within the bladder. This property helps in maintaining urinary tract health and preventing recurrent UTIs. Choices A, B, and D are incorrect because while vitamin C in orange juice may have some benefits, it is not specifically known for deterring bacterial growth in the urinary tract. Apple juice does not significantly impact urine acidity, and grapefruit juice does not enhance antibiotic absorption, making them less effective choices for preventing UTIs compared to cranberry juice.

5. The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?

• A. Monitoring Your Blood Pressure at Home
• B. Smoking Cessation as a Lifelong Commitment
• C. Decreasing Cholesterol Levels Through Diet
• D. Stress Management for a Healthier You

Correct answer: C

Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.

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