Nursing Elites

1. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

• A. A Glasgow Coma Scale score of 13
• B. Clear fluid leaking from the nose
• C. Nausea and vomiting
• D. Anisocoria

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

2. A nurse is providing discharge teaching to a client who has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take your pulse before taking the medication.
• B. Take the medication with an antacid.
• C. Double the dose if you miss one.
• D. Take the medication with a high-fiber meal.

Correct answer: A

Rationale: The correct answer is A: 'Take your pulse before taking the medication.' When administering digoxin, it is crucial to monitor the pulse rate because digoxin can cause bradycardia (slow heart rate). Checking the pulse helps in assessing the heart rate before taking the medication, as bradycardia is a common side effect of digoxin. Choice B is incorrect because digoxin should not be taken with antacids, as they can reduce its absorption. Choice C is incorrect; the dose should never be doubled if a dose is missed. Choice D is incorrect because taking digoxin with a high-fiber meal can also affect its absorption. Therefore, the essential instruction for the client is to monitor the pulse before taking digoxin.

3. A healthcare provider is assessing a client who has fluid volume excess. Which of the following findings should the healthcare provider expect?

• A. Hypotension
• B. Bradycardia
• C. Crackles in the lungs
• D. Dry mucous membranes

Correct answer: C

Rationale: Crackles in the lungs are indicative of fluid accumulation in the alveoli, which is a characteristic finding in clients with fluid volume excess. The crackling sound occurs due to the presence of excess fluid in the lungs, impairing normal ventilation and gas exchange. Monitoring for crackles is essential for early detection and management of fluid overload in clients. Choices A, B, and D are incorrect because in fluid volume excess, hypervolemia leads to increased blood pressure (not hypotension), compensatory tachycardia (not bradycardia), and moist mucous membranes (not dry).

4. A client has been prescribed enoxaparin. Which of the following instructions should the nurse include?

• A. You need to obtain routine blood tests to monitor the effects of this medication.
• B. You should administer the medication into your thigh.
• C. You should inject the medication once daily.
• D. You need to use a 1-inch needle to administer the medication.

Correct answer: C

Rationale: The correct instruction to include when educating a client prescribed enoxaparin is to inject the medication once daily. Enoxaparin is typically administered via subcutaneous injection once daily, usually in the abdomen, to prevent blood clots.

5. A client with a new diagnosis of hyperlipidemia is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my intake of fiber.
• B. I will increase my intake of red meat.
• C. I will decrease my intake of saturated fats.
• D. I will increase my intake of salt.

Correct answer: C

Rationale: The correct answer is C. Decreasing saturated fats is essential in managing hyperlipidemia. Saturated fats can raise LDL cholesterol levels, contributing to the condition. By reducing intake of saturated fats, the client can help lower their cholesterol levels and improve their overall lipid profile. Choices A, B, and D are incorrect. Decreasing fiber intake (Choice A) is not recommended as fiber can help lower cholesterol levels. Increasing red meat intake (Choice B) is not advisable as red meat is often high in saturated fats. Increasing salt intake (Choice D) is unrelated to managing hyperlipidemia and can even be detrimental due to its association with high blood pressure.

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