Nursing Elites

1. A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?

• A. Administer pain medication as ordered.
• B. Check the client's blood pressure.
• C. Place the client in a supine position.
• D. Increase the client's fluid intake.

Correct answer: B

Rationale: The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.

2. A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?

• A. Administer an IV fluid bolus.
• B. Check the surgical site for bleeding.
• C. Place the client in a Trendelenburg position.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: Checking the surgical site for bleeding is crucial in this situation as it helps determine if the drop in blood pressure is due to hemorrhage, a potential postoperative complication. Identifying and addressing bleeding promptly is essential to prevent further complications and stabilize the client's condition.

3. A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

• A. Decreased serum calcium level
• B. Decreased level of serum lipids
• C. Decreased erythrocyte sedimentation rate (ESR)
• D. Increased platelet count

Correct answer: A

Rationale: In fat embolism syndrome (FES), fat globules enter the bloodstream and can lead to various complications, including a decrease in serum calcium levels. This occurs due to the formation of fat emboli in the vessels, which can interfere with calcium metabolism. Therefore, a decreased serum calcium level is an expected laboratory finding in a client with fat embolism syndrome.

4. A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?

• A. Increase protein intake.
• B. Limit fluid intake to 1500 mL/day.
• C. Consume a low-sodium diet.
• D. Take a daily multivitamin.

Correct answer: C

Rationale: For a client with cirrhosis experiencing ascites, the nurse should instruct them to consume a low-sodium diet. This dietary modification helps reduce fluid retention and manage ascites by decreasing the amount of sodium in the body, which helps prevent fluid accumulation in the abdomen. Limiting sodium intake is crucial in managing ascites and preventing further complications in clients with cirrhosis.

5. A client reports a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?

• A. Carbon monoxide poisoning
• B. Heat stroke
• C. Hypersensitivity reaction
• D. Oxygen toxicity

Correct answer: A

Rationale: When a client reports headache and vertigo after turning on the furnace for the first time, it suggests carbon monoxide poisoning. Carbon monoxide is an odorless, colorless gas that can be released by malfunctioning heating systems. Symptoms of carbon monoxide poisoning include headache, dizziness, weakness, nausea, and confusion. It is crucial for the nurse to suspect this condition promptly to ensure the client's safety and well-being.

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