Nursing Elites

1. A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?

• A. A client who is NPO and has dry mucous membranes
• B. A client with rotavirus who has been vomiting
• C. A client who has a urinary catheter and cloudy urine
• D. A client who has pneumonia and a new onset of confusion

Correct answer: D

Rationale: The correct answer is D because a client with pneumonia and a new onset of confusion needs immediate evaluation for changes in neurological status. This could indicate a decline in respiratory status or potential complications such as hypoxia or sepsis. Option A, a client who is NPO and has dry mucous membranes, may need intervention but does not indicate an acute change in condition. Option B, a client with rotavirus who has been vomiting, requires assessment and intervention but does not pose an immediate threat to life. Option C, a client with a urinary catheter and cloudy urine, may indicate a urinary tract infection but does not require immediate attention compared to the client with new onset confusion and pneumonia.

2. What are the nursing considerations when administering blood products?

• A. Monitor vital signs and check for allergic reactions
• B. Verify blood type and compatibility before transfusion
• C. Monitor for signs of infection and sepsis
• D. Ensure consent is signed and prepare for possible reaction

Correct answer: A

Rationale: The correct answer is A: Monitor vital signs and check for allergic reactions. When administering blood products, monitoring vital signs such as blood pressure, heart rate, and temperature is crucial to detect any adverse reactions promptly. Checking for allergic reactions, such as hives, itching, or difficulty breathing, is essential to ensure patient safety. Choice B is incorrect because verifying blood type and compatibility is typically done by the laboratory before the blood is issued for transfusion. Choice C is not a direct nursing consideration during the administration of blood products. While monitoring for signs of infection and sepsis is important in general patient care, it is not specific to blood transfusions. Choice D is also incorrect as ensuring consent is signed and preparing for possible reactions are important but do not directly relate to the immediate nursing considerations during blood product administration.

3. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.

4. What are the major risk factors for stroke?

• A. Hypertension, high cholesterol, and smoking
• B. Obesity and lack of exercise
• C. Family history of cardiovascular disease
• D. Age and gender

Correct answer: A

Rationale: The correct answer is A: Hypertension, high cholesterol, and smoking are major risk factors for stroke. These factors contribute to the development of atherosclerosis, which can lead to a stroke. While obesity and lack of exercise are risk factors for cardiovascular diseases, they are not as directly linked to stroke as hypertension, high cholesterol, and smoking. Family history of cardiovascular disease may increase the overall risk of heart problems, but it is not as specific to stroke as the factors listed in option A. Age and gender can influence the risk of stroke, but they are not modifiable risk factors like hypertension, high cholesterol, and smoking, which can be reduced through lifestyle changes.

5. A nurse is working in an acute care mental health facility and is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?

• A. All-or-nothing thinking.
• B. Euphoric mood.
• C. Disorganized speech.
• D. Hypochondriasis.

Correct answer: C

Rationale: The correct answer is C: Disorganized speech. Disorganized speech is a hallmark symptom of schizophrenia, characterized by impaired thought processes that lead to incoherent, disjointed communication. All-or-nothing thinking (Choice A) is more commonly associated with cognitive distortions seen in conditions like anxiety disorders. Euphoric mood (Choice B) is not a typical finding in schizophrenia, as individuals with this disorder often display a flat or blunted affect. Hypochondriasis (Choice D) involves a preoccupation with having a serious illness and is not a primary symptom of schizophrenia.

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