Nursing Elites

1. A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take?

• A. Ensure that the width of the BP cuff is appropriate for the client's arm circumference.
• B. Reposition the client supine and recheck their BP.
• C. Recheck the client's BP and measure their other arm for comparison.
• D. Request that another nurse check the client's BP in 30 minutes.

Correct answer: C

Rationale: When a nurse obtains a blood pressure reading that is elevated, the appropriate action is to recheck the client's BP and measure the other arm for comparison. This step helps ensure accuracy by ruling out errors like improper cuff size, positioning, or equipment malfunction. Repositioning the client supine is not necessary unless the client shows signs of distress or symptoms. Ensuring the appropriate cuff width is important for accurate readings but does not address the immediate need to confirm the current BP. Requesting another nurse to check the BP in 30 minutes delays immediate action and does not address the need for verification and comparison of the current reading.

2. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

• A. Apply the stockings with the creases on the front of the leg.
• B. Apply the stockings while the client's legs are in a dependent position.
• C. Remove the stockings at least once per shift.
• D. Remove the stockings while the client is sitting in a reclining chair.

Correct answer: C

Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.

3. A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?

• A. Decreased calcium
• B. Elevated potassium
• C. Increased sodium
• D. Low hemoglobin

Correct answer: A

Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.

4. A patient with stomatitis is receiving oral care education from a nurse. Which instructions will the nurse provide?

• A. Avoid commercial mouthwashes.
• B. Avoid normal saline rinses.
• C. Brush with a hard toothbrush.
• D. Brush with an alcohol-based toothpaste.

Correct answer: A

Rationale: The correct instruction for a patient with stomatitis is to avoid commercial mouthwashes. Commercial mouthwashes often contain alcohol and other ingredients that can irritate the already inflamed oral mucosa in patients with stomatitis. Avoiding commercial mouthwashes helps prevent further irritation and discomfort. Choice B is incorrect because normal saline rinses are gentle and can help soothe the oral mucosa in patients with stomatitis. Choice C is incorrect because a soft toothbrush should be used to prevent further irritation or injury to the gums. Choice D is incorrect because an alcohol-based toothpaste can be too harsh and drying for patients with stomatitis.

5. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states, 'I demand to be released now!' The appropriate action is for the nurse to:

• A. You cannot be released because you are still suicidal.
• B. You can be released only if you sign a no-suicide contract.
• C. Let's discuss your decision to leave and then we can prepare you for discharge.
• D. You have a right to sign out as soon as we get an order from the healthcare provider's discharge order.

Correct answer: C

Rationale: The correct action for the nurse in this scenario is to engage the client in a discussion about their decision to leave and then prepare them for discharge. This approach allows the nurse to assess the client's current state, address concerns, and plan for a safe discharge. Option A is incorrect because it does not involve a therapeutic communication approach and may escalate the situation. Option B is incorrect as it places a condition on the client for release, which is not recommended in this situation. Option D is incorrect as it does not prioritize the client's autonomy and right to make decisions about their care.

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