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. When is the first dose of Hepatitis B vaccine typically administered?

• A. In the hospital at birth
• B. At one year old
• C. At six months
• D. At 18 months

Correct answer: A

Rationale: The first dose of the Hepatitis B vaccine is usually administered at birth in the hospital to provide early protection against the virus. Giving the vaccine at birth helps prevent perinatal transmission of Hepatitis B from an infected mother to her newborn. This early administration is crucial in establishing immunity in infants, as delaying the vaccine increases the risk of infection. Options B, C, and D are incorrect because delaying the administration of the Hepatitis B vaccine can leave infants vulnerable to the virus during the critical early months of life when they are most susceptible.

3. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

• A. Encourage the client to increase ambulation in the room.
• B. Offer the client a high-carbohydrate snack for energy.
• C. Force fluids to thin the client's pulmonary secretions.
• D. Determine if pain is causing the client's tachypnea.

Correct answer: D

Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.

4. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

5. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low density lipoproteins needs to increase.

Correct answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

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