Nursing Elites

1. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

• A. CT scan
• B. MRI
• C. X-ray
• D. Ultrasound

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

2. A client scheduled for a CT scan of the head with contrast is being taught by a nurse. Which of the following statements by the client indicates a need for further teaching?

• A. I will not eat or drink for 4 hours before the procedure
• B. I will keep my head still throughout the procedure
• C. I will experience a warm sensation when the dye is injected
• D. I can take my morning dose of metformin

Correct answer: D

Rationale: The correct answer is D because metformin should be held before a contrast CT scan to prevent the risk of kidney damage. Choices A, B, and C are all correct statements regarding the preparation and experience of a CT scan with contrast. It is important to fast before the procedure, keep the head still during the scan, and expect a warm sensation when the dye is injected.

3. What is the most important action for the nurse to take before administering digoxin to a patient?

• A. Check the patient's heart rate before administration.
• B. Assess the patient's blood pressure before administration.
• C. Ensure the patient has eaten before administration.
• D. Monitor the patient's weight before administration.

Correct answer: A

Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.

4. During an initial visit, a home health nurse is assessing a client who has cultural beliefs different from their own. Which of the following questions should the nurse ask to determine the client's beliefs about environmental control?

• A. Do you spend more time thinking about the past, present, or future?
• B. Who makes most of the decisions in your family group?
• C. What do you think you can do to affect your health status?
• D. Can you list any diseases that your parents or siblings have had?

Correct answer: C

Rationale: The correct question to ask in this scenario is: 'What do you think you can do to affect your health status?' This question directly addresses the client's beliefs about their ability to control their health and reflects their beliefs about environmental control. Choices A, B, and D do not directly relate to assessing the client's beliefs about environmental control. Choice A focuses on time orientation, choice B pertains to family decision-making dynamics, and choice D is related to family medical history, which are not directly relevant to understanding the client's beliefs about environmental control.

5. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?

• A. Notify the family and await further instructions.
• B. Initiate CPR and call for emergency assistance.
• C. Allow the family to make decisions about care.
• D. Follow the family's wishes and perform no interventions.

Correct answer: B

Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.

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