Nursing Elites

1. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

• A. List of prescribed medications
• B. Potential complications to report
• C. Family contact details
• D. Dietary restrictions

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

2. What are the signs of an acute myocardial infarction?

• A. Chest pain radiating to the arm and shortness of breath
• B. Nausea, vomiting, and high fever
• C. Headache, confusion, and low blood pressure
• D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

3. A client post-surgery has a chest tube. What is the most important assessment for the nurse to perform?

• A. Clamp the chest tube for 30 minutes every 4 hours
• B. Check for air leaks and ensure the chest tube is functioning properly
• C. Position the client in a high Fowler's position
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the chest tube is functioning properly. This is crucial post-surgery to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube, positioning the client, or encouraging coughing are not appropriate assessments for a client with a chest tube post-surgery and could lead to serious issues if done incorrectly.

4. A client who is to undergo an exercise stress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should eat a large meal 2 hours before the test
• B. I should avoid drinking water before the test
• C. I should stop taking my blood pressure medication
• D. I should report any chest pain during the test

Correct answer: D

Rationale: The correct answer is D: 'I should report any chest pain during the test.' This statement indicates an understanding of the teaching because reporting chest pain during an exercise stress test is crucial as it may signify cardiac distress. Choices A, B, and C are incorrect. Eating a large meal 2 hours before the test is not recommended as it may affect the results. Avoiding drinking water before the test is also not advisable as staying hydrated is important. Stopping blood pressure medication without medical advice can be dangerous, especially before a stress test.

5. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate (TURP). Which of the following should the nurse identify as a priority nursing assessment after reviewing the client's information?

• A. Level of consciousness.
• B. Skin turgor.
• C. Deep-tendon reflexes.
• D. Bowel sounds.

Correct answer: A

Rationale: The correct answer is A: Level of consciousness. Following a TURP procedure, monitoring the client's level of consciousness is crucial as it can indicate potential postoperative complications such as hemorrhage or shock. Skin turgor (choice B) is more related to hydration status, deep-tendon reflexes (choice C) are not the priority post-TURP, and bowel sounds (choice D) are important but not the priority in this situation.

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