Nursing Elites

1. When assessing constipation in elders, which action should be the nurse's priority?

• A. Obtain a complete blood count
• B. Obtain a health and dietary history
• C. Refer to a provider for a physical examination
• D. Measure height and weight

Correct answer: B

Rationale: The correct answer is to obtain a health and dietary history when assessing constipation in elders. This action is crucial as it helps the nurse identify potential causes and contributing factors to constipation in elderly clients. Obtaining a complete blood count (choice A) may be necessary at some point, but it is not the priority in this situation. Referring to a provider for a physical examination (choice C) and measuring height and weight (choice D) are important but are not the priority actions when assessing constipation.

2. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?

• A. A heart rate of 72 beats per minute
• B. A blood pressure of 110/70 mm Hg
• C. Pupils equal and reactive to light
• D. Client reports headache

Correct answer: C

Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.

3. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

• A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
• B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
• C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
• D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.

Correct answer: A

Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.

4. The client with congestive heart failure has been educated about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

• A. Cheese sandwich with a glass of 2% milk
• B. Sliced turkey sandwich and canned pineapple
• C. Cheeseburger and baked potato
• D. Mushroom pizza and ice cream

Correct answer: B

Rationale: The correct answer is B: Sliced turkey sandwich and canned pineapple. This lunch choice is suitable for a client with congestive heart failure as it is low in sodium. Sliced turkey is a lean protein choice, and canned pineapple is a low-sodium fruit option. Choice A contains high-sodium items like cheese and 2% milk. Choice C includes a cheeseburger, which is typically high in sodium, and a baked potato could also be high in sodium depending on preparation. Choice D consists of mushroom pizza and ice cream, both of which can be high in sodium, especially in processed or restaurant-prepared forms.

5. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

• A. Stay with the client and observe for airway obstruction
• B. Collect pillows and pad the side rails of the bed
• C. Place an oral airway in the mouth and suction
• D. Announce a cardiac arrest and assist with intubation

Correct answer: A

Rationale: The correct action for the nurse to take next is to stay with the client and observe for airway obstruction. This is crucial as it ensures immediate intervention if there is any airway compromise. Choice B is incorrect as padding the side rails of the bed is not the priority in this situation. Choice C is incorrect because inserting an oral airway and suctioning should only be done if there is evidence of airway obstruction, and it is not the initial step. Choice D is incorrect as announcing a cardiac arrest and assisting with intubation is not the immediate action needed when a client is seizing and losing consciousness.

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