Nursing Elites

1. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?

• A. A client who is 1 hr postoperative and has hypoactive bowel sounds.
• B. A client who has a fractured left tibia and pallor in the affected extremity.
• C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses.
• D. A client who has an elevated AST level following the administration of azithromycin.

Correct answer: B

Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.

2. Which of the following interventions should the nurse prioritize for a client with dementia who is at risk of falls?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm system to notify staff when the client attempts to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct answer is B. Using a bed exit alarm system is a non-restrictive intervention that alerts staff when the client tries to leave the bed, promoting safety and preventing falls. Choice A is incorrect because using restraints can have adverse effects and should be avoided whenever possible. Choice C is not the priority for a client at risk of falls due to dementia as it may increase the risk of falls without proper supervision. Choice D is also not recommended as raising all four side rails can lead to restraint and should be used cautiously, if at all. Therefore, the best option is to use a bed exit alarm system to ensure the client's safety while allowing some freedom of movement.

3. 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.

4. What are the early signs of heart failure in a patient?

• A. Shortness of breath and weight gain
• B. Fatigue and chest pain
• C. Nausea and vomiting
• D. Cough and elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. Early signs of heart failure typically manifest as shortness of breath due to fluid accumulation in the lungs and weight gain due to fluid retention in the body. Choices B, C, and D are incorrect. Fatigue and chest pain are symptoms commonly associated with heart conditions but are not specific early signs of heart failure. Nausea and vomiting are not typically early signs of heart failure. Cough can be a symptom of heart failure, but it is usually associated with other symptoms like shortness of breath rather than being an isolated early sign. Elevated blood pressure is not an early sign of heart failure; in fact, heart failure is more commonly associated with low blood pressure.

5. A healthcare provider is providing discharge teaching to a client who is recovering from acute pancreatitis. Which of the following instructions should the healthcare provider include?

• A. Consume a low-fat diet.
• B. Limit your carbohydrate intake.
• C. Increase your protein intake.
• D. Take acetaminophen for pain management.

Correct answer: A

Rationale: Clients recovering from acute pancreatitis should consume a low-fat diet to reduce the workload on the pancreas and prevent exacerbation. This diet helps in minimizing the stimulation of pancreatic enzyme secretion, which aids in the recovery process. Choices B, C, and D are incorrect as limiting carbohydrate intake or increasing protein intake may not be necessary for acute pancreatitis, and acetaminophen may not be the first-line choice for pain management in this condition.

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