Nursing Elites

1. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

• A. I can give you information about respite care if you are interested.
• B. You should consider taking a sleeping pill before bed each night.
• C. It must be difficult taking care of someone who is terminally ill.
• D. You are doing a great job taking care of your mother.

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

2. When managing blood pressure at home, which statement by the client indicates an understanding of the teaching provided by a nurse for hypertension?

• A. I will take my medication only when I feel dizzy.
• B. I will check my blood pressure at least once a week.
• C. I will stop taking my medication once my blood pressure is within normal range.
• D. I will sit quietly for 5 minutes before measuring my blood pressure.

Correct answer: D

Rationale: The correct answer is D because sitting quietly for 5 minutes before measuring blood pressure ensures an accurate reading and helps monitor hypertension. Choice A is incorrect as medications for hypertension should be taken as prescribed, not based on symptoms like dizziness. Choice B is not ideal as blood pressure should be checked more frequently, preferably daily. Choice C is incorrect as stopping medication abruptly once blood pressure is normal can lead to rebound hypertension.

3. A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Blood pressure 110/70 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

4. A healthcare professional is reviewing the laboratory results of a client who is receiving chemotherapy. Which of the following findings should the healthcare professional report immediately?

• A. White blood cell count of 4,500/mm³
• B. Hemoglobin level of 8 g/dL
• C. Platelet count of 90,000/mm³
• D. Serum potassium level of 3.5 mEq/L

Correct answer: C

Rationale: A platelet count of 90,000/mm³ indicates thrombocytopenia, which increases the risk of bleeding and requires immediate intervention. Thrombocytopenia can lead to serious bleeding complications, so it is crucial to address this finding promptly. A low white blood cell count (choice A) may indicate neutropenia but is not as immediately life-threatening as severe thrombocytopenia. A hemoglobin level of 8 g/dL (choice B) would require intervention but is not as urgent as addressing a critically low platelet count. A serum potassium level of 3.5 mEq/L (choice D) is on the lower side of normal but does not pose an immediate risk to the client's safety compared to severe thrombocytopenia.

5. A nurse is providing teaching to a client who is postoperative following a cataract extraction. Which of the following statements should the nurse include?

• A. You should expect to have eye pain for the first 2 days after surgery.
• B. You should bend at the waist to pick up objects from the floor.
• C. You should avoid sleeping on the side of the body that was operated on.
• D. You should wear an eye shield at night for 2 weeks.

Correct answer: D

Rationale: The correct answer is D. After cataract surgery, wearing an eye shield at night for 2 weeks is essential to protect the eye during the initial healing period. Choice A is incorrect because significant eye pain should not be expected for the first 2 days after surgery. Choice B is incorrect as bending at the waist can increase intraocular pressure, which should be avoided postoperatively. Choice C is incorrect as there is no need to avoid sleeping on the side of the body that was operated on after cataract surgery.

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