Nursing Elites

1. Signs and symptoms of stroke may include all of the following EXCEPT:

• A. Sudden weakness or numbness of the face, arm, or leg.
• B. Sudden confusion.
• C. Sudden headache with no known cause.
• D. Hypotension.

Correct answer: D

Rationale: Hypotension is not a typical sign or symptom of an acute stroke. The correct signs and symptoms of a stroke include sudden weakness or numbness of the face, arm, or leg, sudden confusion, and a sudden headache with no known cause. Hypotension, which refers to low blood pressure, is not a common indicator of a stroke. It is important to differentiate between hypotension and hypertension in the context of stroke symptoms, as hypertension (high blood pressure) is actually a risk factor for strokes. Sudden weakness, numbness, confusion, and headache are signs associated with a stroke due to a disruption in blood flow to the brain. Hypotension, on the other hand, primarily indicates low blood pressure and is not directly linked to the typical presentation of a stroke.

2. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for a morphine drip is not working?

• A. The client complains of discomfort at the IV insertion site
• B. The client states 'I just can't get relief from my pain.'
• C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
• D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon

Correct answer: C

Rationale: The correct answer is that the level of the drug is 100 ml at 8 AM and is 80 ml at noon. With a basal rate of 10 mL per hour, a total of 40 mL should have been infused by noon, leaving only 60 mL in the container. Any amount greater than 60 mL at noon indicates that the pump is not functioning properly. Therefore, the finding of 80 mL at noon suggests the pump is not delivering the expected medication volume. Choices A and B are related to the client's symptoms and may indicate the need for pain management assessment but do not specifically indicate pump malfunction. Choice D, where the level drops to 50 mL at noon, would actually indicate that the pump is working effectively, as the expected volume has been delivered.

3. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

• A. Focus on your sons' needs during the first days at home.
• B. Tell each child what he can do to help with the baby.
• C. Suggest that your husband spend more time with the boys.
• D. Ask the children what they would like to do for the newborn.

Correct answer: A

Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.

4. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?

• A. Protect the neonate's eyes from the heat lamp
• B. Monitor the neonate's temperature
• C. Warm all medications and liquids before administration
• D. Avoid touching the neonate with cold hands

Correct answer: B

Rationale: When a newborn is placed in a warming isolette due to difficulty maintaining temperature, the priority action is to continuously monitor the neonate's temperature to prevent overheating. Using heat lamps is unsafe as their temperature cannot be regulated, potentially causing harm. Warming medications and fluids before administration is not necessary in this situation. While touching the neonate with cold hands may startle them, it does not pose a safety risk compared to monitoring and controlling the temperature.

5. A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?

• A. Administer anticoagulant drug therapy.
• B. Notify the patient's healthcare provider.
• C. Prepare the patient for a spiral computed tomography (CT).
• D. Elevate the head of the bed to a semi-Fowler's position.

Correct answer: D

Rationale: The patient presents with symptoms indicative of a pulmonary embolism (PE), such as chest pain, difficulty breathing, tachycardia, hypotension, and tachypnea. Elevating the head of the bed to a semi-Fowler's position is the priority to improve ventilation and gas exchange. This intervention should be initiated promptly to optimize oxygenation. Subsequent actions, such as notifying the healthcare provider, preparing for a spiral CT scan, and administering anticoagulant therapy, can follow after the patient's position is adjusted. The spiral CT scan is typically used to confirm the diagnosis of PE, and anticoagulant therapy is initiated upon confirmation of the diagnosis by the healthcare provider. Therefore, the immediate focus is on improving the patient's respiratory status by elevating the head of the bed.

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