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 with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?

• A. Monitoring blood pressure
• B. Checking the activated partial thromboplastin time (aPTT)
• C. Assessing for signs of bleeding
• D. Measuring calf circumference

Correct answer: C

Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.

3. A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?

• A. I will reduce my sodium intake to help control my blood pressure.
• B. I need to start walking at least 30 minutes most days of the week.
• C. I can continue drinking alcohol as long as it is not in excess.
• D. I will check my blood pressure regularly at home.

Correct answer: C

Rationale: In hypertension management, it is crucial for clients to limit or avoid alcohol consumption, not just refrain from excess. Alcohol can raise blood pressure and interfere with the effectiveness of antihypertensive medications, making it a key lifestyle modification for individuals with hypertension.

4. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

• A. Kussmaul respirations
• B. Apneustic respirations
• C. Cheyne-Stokes respirations
• D. Stridor

Correct answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

5. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?

• A. Applying suction while withdrawing the catheter
• B. Preoxygenating the client before suctioning
• C. Suctioning up to three times if necessary
• D. Suctioning for a duration of 10 to 15 seconds each time

Correct answer: A

Rationale: The correct technique for suctioning a tracheostomy involves applying suction while withdrawing the catheter to avoid damaging the tracheal mucosa. Therefore, the student applying suction while inserting the catheter indicates a need for further teaching. Preoxygenating the client, suctioning up to three times if necessary, and limiting suctioning to 10 to 15 seconds each time are all appropriate actions in tracheostomy suctioning.

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