Nursing Elites

1. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?

• A. Encourage the patient to walk in the hall alone
• B. Discourage the patient from walking in the hall for a few more days
• C. Accompany the patient for his walk
• D. Consult a physical therapist before allowing the patient to ambulate

Correct answer: C

Rationale: Accompanying the patient for his walk is the appropriate nursing intervention in this scenario to ensure his safety during his first ambulation. This allows the nurse to provide immediate assistance if needed and ensures the patient's well-being during this critical postoperative period.

2. If a patient's blood pressure is 150/96, what is his pulse pressure?

• A. 54
• B. 96
• C. 150
• D. 246

Correct answer: A

Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, the systolic pressure is 150 and the diastolic pressure is 96. Therefore, the pulse pressure is 150 - 96 = 54. Pulse pressure represents the force generated by the heart with each contraction and is an important indicator of cardiovascular health.

3. When assessing a client with a history of asthma, which of the following factors should the nurse identify as a risk for asthma?

• A. Gender
• B. Environmental allergies
• C. Alcohol
• D. None of the above

Correct answer: B

Rationale: When assessing a client with a history of asthma, the nurse should identify environmental allergies as a risk factor for asthma. Environmental allergens such as pollen, dust mites, mold, and pet dander can trigger asthma symptoms and exacerbate the condition. Gender, alcohol consumption, and other factors may not directly contribute to the development or exacerbation of asthma.

4. The client is receiving discharge teaching for a new prescription of phenelzine. The nurse should instruct the client that it is not safe to eat which of the following foods while taking this medication?

• A. whole grain bread
• B. Avocados
• C. Smoked salmon
• D. Pepperoni pizza

Correct answer: B

Rationale: Avocados contain high levels of tyramine, which can cause a hypertensive crisis when consumed with phenelzine, a monoamine oxidase inhibitor (MAOI). It is essential for clients taking MAOIs to avoid foods rich in tyramine to prevent dangerous interactions and potential health risks.

5. A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

• A. Chest pain
• B. Muscle spasms
• C. Cool, moist skin
• D. Incisional pain

Correct answer: A

Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.

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