Nursing Elites

1. The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings?

• A. Refer the client to a nutritionist after providing health teaching about a low-sodium diet.
• B. Place the client in a recumbent position and call the paramedics for transport to the hospital.
• C. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service.
• D. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

Correct answer: D

Rationale: The appropriate nursing action in response to significantly high blood pressure readings like 172/104 mm Hg and 164/98 mm Hg is to confirm the readings by taking the blood pressure in the other arm. This can help rule out any error or issue specific to that arm. The nurse should then schedule a healthcare practitioner's appointment for as soon as possible to further assess the client's condition and determine the appropriate intervention. Choice A is incorrect because solely referring the client to a nutritionist for a low-sodium diet without further assessment or confirmation of the blood pressure readings is premature. Choice B is incorrect as the client is already seated, and calling paramedics for immediate transport to the hospital is not warranted based solely on the blood pressure readings provided. Choice C is incorrect as stress may not be the sole reason for the high blood pressure readings, and further assessment is required before referring the client to counseling services.

2. Which finding would be the most characteristic of an acute episode of reactive airway disease?

• A. Auditory gurgling
• B. Inspiratory laryngeal stridor
• C. Auditory expiratory wheezing
• D. Frequent dry coughing

Correct answer: C

Rationale: The correct answer is C: Auditory expiratory wheezing. Expiratory wheezing is a common sign of reactive airway disease, such as asthma, where airways are constricted, making it difficult to expel air from the lungs. Choices A, B, and D are incorrect as they are not typically associated with reactive airway disease. Auditory gurgling may suggest airway secretions or fluid accumulation, inspiratory laryngeal stridor indicates upper airway obstruction, and frequent dry coughing is more commonly seen in conditions like upper respiratory infections or postnasal drip.

3. A 14-month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?

• A. Hot dog, carrot sticks, gelatin, milk
• B. Soup, blenderized soft foods, ice cream, milk
• C. Peanut butter and jelly sandwich, chips, pudding, milk
• D. Baked chicken, applesauce, cookie, milk

Correct answer: B

Rationale: Choice B, 'Soup, blenderized soft foods, ice cream, milk,' is the correct answer. After cleft palate repair, it is essential to provide soft and blenderized foods to prevent trauma to the surgical site and promote proper healing. Choices A, C, and D contain foods that may be difficult for the child to consume comfortably and safely after a cleft palate surgical repair. A hot dog, carrot sticks, chips, and hard cookies could potentially cause injury or discomfort to the surgical area. Peanut butter and jelly sandwich might be too difficult to swallow or may stick to the surgical site. Baked chicken could be too challenging to chew. Therefore, the best choice for an appropriate meal post cleft palate repair is soft, blenderized foods like soup, along with other soft options like ice cream and milk.

4. A 23-year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?

• A. Acceptance of the pregnancy
• B. Focus on fetal development
• C. Anticipation of the birth
• D. Ambivalence about pregnancy

Correct answer: C

Rationale: The correct answer is C: 'Anticipation of the birth.' In the third trimester, it is common for expectant mothers to feel excited and prepared for the upcoming birth of their baby. This includes making plans for the baby's arrival and the early days at home. Choice A, 'Acceptance of the pregnancy,' may occur earlier in the pregnancy and does not specifically relate to the third trimester. Choice B, 'Focus on fetal development,' is more common in the earlier stages of pregnancy when the mother may be more concerned with the baby's growth and milestones. Choice D, 'Ambivalence about pregnancy,' suggests conflicting feelings which are less likely in this scenario where the client expresses readiness and plans for the baby's arrival.

5. When caring for premature newborns in an intensive care setting, a nurse carefully monitors oxygen concentration. What is the most common complication of this therapy?

• A. Intraventricular hemorrhage
• B. Retinopathy of prematurity
• C. Bronchopulmonary dysplasia
• D. Necrotizing enterocolitis

Correct answer: B

Rationale: Retinopathy of prematurity is the most common complication in premature infants exposed to high concentrations of oxygen. This condition leads to abnormal blood vessel growth in the retina, which can potentially result in blindness if not managed promptly. Intraventricular hemorrhage, though a significant concern in premature infants, is not directly related to oxygen therapy. Bronchopulmonary dysplasia is primarily associated with mechanical ventilation and oxygen exposure over time, not specifically with oxygen concentration monitoring. Necrotizing enterocolitis is more linked to gastrointestinal issues and is not the most common complication of oxygen therapy in premature newborns.

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