Nursing Elites

1. A nursing student asks what essential hypertension is. What response by the registered nurse is best?

• A. It means it is caused by another disease.
• B. It means it is essential that it be treated.
• C. It is hypertension with no specific cause.
• D. It refers to severe and life-threatening hypertension.

Correct answer: C

Rationale: Essential hypertension, also known as primary or idiopathic hypertension, is the most common type of hypertension. It has no specific underlying cause such as an associated disease process. In contrast, hypertension that is due to another disease is referred to as secondary hypertension. Malignant hypertension is a severe and life-threatening form of hypertension characterized by rapidly progressive blood pressure elevation and potential end-organ damage.

2. A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

• A. Perform range-of-motion exercises
• B. Place suction equipment at the bedside
• C. Encourage the use of an incentive spirometer
• D. Administer an expectorant

Correct answer: C

Rationale: Encouraging the use of an incentive spirometer is vital in preventing pulmonary complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, promoting lung expansion, and preventing atelectasis. Range-of-motion exercises help prevent musculoskeletal complications, while placing suction equipment at the bedside is important but not directly related to preventing pulmonary complications. Administering an expectorant may help with clearing secretions but is not as effective in preventing postoperative pulmonary complications as using an incentive spirometer.

3. A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?

• A. Take the medication with food to avoid stomach upset.
• B. Avoid exposure to sunlight while taking this medication.
• C. Report any numbness or tingling in extremities.
• D. Have liver function tests done regularly.

Correct answer: D

Rationale: Regular monitoring of liver function tests is crucial for clients taking isoniazid (INH) due to the potential risk of hepatotoxicity. Isoniazid can cause liver damage, and early detection through routine liver function tests can help prevent severe complications.

4. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

5. A client with tuberculosis is starting medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?

• A. Take isoniazid with an antacid.
• B. Provide a sputum specimen every 2 weeks to the clinic for testing.
• C. Expect your sputum cultures to be negative after 6 months of therapy.
• D. Drink at least 8 ounces of water when you take the pyrazinamide tablet.

Correct answer: D

Rationale: Pyrazinamide can cause gastrointestinal upset and is best taken with a full glass of water to minimize irritation to the stomach lining. This instruction helps reduce the risk of adverse effects associated with pyrazinamide. Options A and C are not directly related to the medication regimen for tuberculosis. While sputum testing is important, the frequency mentioned in option B is not required every two weeks.

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