Nursing Elites

1. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

2. A client is preparing for surgery wearing a necklace. What is the appropriate action?

• A. Remove the necklace and place it in a drawer
• B. Tape the necklace to the patient's skin
• C. Ask the patient for permission to lock it in a safe
• D. Ask the family to hold onto the necklace

Correct answer: C

Rationale: The appropriate action when a client is wearing a necklace before surgery is to ask the patient for permission to lock it in a safe. This is in line with hospital policy to secure valuables before entering surgery. Choice A is incorrect because simply placing the necklace in a drawer may not be secure. Choice B is incorrect as taping the necklace to the patient's skin can cause skin irritation and is not a standard practice. Choice D is incorrect because the responsibility for securing valuables typically lies with the healthcare team, not the patient's family.

3. Which patient should the nurse see first?

• A. A 1-month-old infant looking at a shiny, round battery just out of arm's reach.
• B. A 56-year-old patient with oxygen and a lighter on the bedside table.
• C. A 56-year-old patient with oxygen using an electric razor for grooming.
• D. A bedridden patient who has a reddened area on the buttocks and needs to be turned.

Correct answer: B

Rationale: The correct answer is B because the patient with oxygen and a lighter on the bedside table is at immediate risk of fire. Oxygen promotes combustion, and having a lighter nearby poses a serious safety hazard. This situation requires urgent attention to prevent a potential disaster. Choices A, C, and D do not present immediate life-threatening risks compared to the patient with oxygen and a lighter nearby.

4. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?

• A. Drink fluids between meals
• B. Eat three large meals each day
• C. Lie down for 30 minutes after meals
• D. Avoid drinking liquids with meals

Correct answer: D

Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.

5. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?

• A. Administer emergency medications without performing CPR
• B. Begin CPR
• C. Call the provider for a do-not-resuscitate (DNR) order
• D. Respect the client's wishes, and do not attempt CPR

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.

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