Nursing Elites

1. During an initial assessment, a healthcare provider notes that a client has elevated blood pressure. Which of the following findings is considered a major risk factor for coronary artery disease?

• A. Elevated HDL cholesterol
• B. Low LDL cholesterol
• C. Elevated blood pressure
• D. Low triglyceride levels

Correct answer: C

Rationale: Elevated blood pressure is a significant risk factor for coronary artery disease because it increases the strain on the arteries, leading to potential damage and a higher risk of developing coronary artery disease. Elevated HDL cholesterol (Choice A) is actually considered beneficial as it helps reduce the risk of heart disease. Low LDL cholesterol (Choice B) is also beneficial as high levels of LDL are associated with an increased risk of coronary artery disease. Low triglyceride levels (Choice D) are not typically considered a major risk factor for coronary artery disease.

2. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. Client with pneumonia who has a fever of 101.5°F
• B. Client who underwent knee surgery and needs dressing change
• C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
• D. Client with diabetes requesting insulin

Correct answer: C

Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.

3. A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?

• A. Limit sodium intake to reduce fluid retention
• B. Consume high-protein foods to strengthen the heart
• C. Increase potassium intake to manage blood pressure
• D. Increase fluid intake to promote hydration

Correct answer: A

Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.

4. A client with type 1 diabetes reports blurry vision. What is the most important assessment the nurse should perform?

• A. Assess the client’s most recent blood glucose levels.
• B. Check the client’s hemoglobin A1C level.
• C. Check the client’s blood pressure for signs of hypertension.
• D. Examine the client’s feet for signs of neuropathy.

Correct answer: A

Rationale: Blurry vision in clients with type 1 diabetes may indicate hyperglycemia, which requires prompt assessment of recent blood glucose levels to determine the cause and appropriate intervention. Checking the client’s hemoglobin A1C level (Choice B) is useful for assessing long-term glucose control, not for immediate management of blurry vision. Monitoring blood pressure (Choice C) is important in diabetes care but is not the most crucial assessment when blurry vision is reported. Examining the client’s feet for signs of neuropathy (Choice D) is important in diabetic foot care but is not the priority when dealing with blurry vision.

5. A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first?

• A. Notify the healthcare provider immediately
• B. Begin continuous fetal monitoring
• C. Check the amniotic fluid pH
• D. Assess maternal vital signs

Correct answer: B

Rationale: Greenish-brown discharge likely indicates meconium in the amniotic fluid, which poses a risk to the fetus. Continuous fetal monitoring should be initiated immediately to assess for signs of fetal distress. Meconium-stained amniotic fluid can lead to meconium aspiration syndrome in the newborn, so timely monitoring is crucial. Checking the amniotic fluid pH can help confirm the presence of meconium but is not the priority over fetal monitoring. Assessing maternal vital signs is important but secondary to monitoring the fetal well-being in this urgent situation. Notifying the healthcare provider can follow once the immediate fetal assessment is underway.

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