Nursing Elites

1. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take if a client is exhibiting an extrapyramidal reaction to psychotropic medications?

• A. Leave a detailed message about the client's condition.
• B. Tell the receptionist to have the healthcare provider return the phone call.
• C. Call another healthcare provider.
• D. Document the attempt to call the healthcare provider.

Correct answer: B

Rationale: The best nursing action is to request a return call from the healthcare provider. When a client is experiencing an extrapyramidal reaction to psychotropic medications, it is crucial to prioritize the client's confidentiality and ensure the information is conveyed to the healthcare provider directly. Leaving a detailed message with a receptionist may compromise the confidentiality of the client's condition. Calling another healthcare provider may delay necessary intervention and continuity of care. Documenting the attempt to call is important for the nurse's records but does not address the immediate need to inform the healthcare provider about the client's condition.

2. When visiting a community health clinic, a client's blood pressure is measured at 146/94. What information should the nurse provide the client?

• A. Participate in an exercise program for 6 weeks
• B. Obtain blood pressure daily for 2 weeks
• C. Increase dietary intake of omega-3 fatty acids
• D. Begin a low sodium diet immediately

Correct answer: D

Rationale: The correct answer is to advise the client to begin a low sodium diet immediately. High sodium intake can contribute to elevated blood pressure levels. By reducing sodium intake, blood pressure can be effectively lowered. Option A, participating in an exercise program, is beneficial for overall health but may not provide immediate impact on blood pressure. Option B, obtaining blood pressure daily for 2 weeks, may not address the underlying cause or provide immediate intervention. Option C, increasing dietary intake of omega-3 fatty acids, though beneficial for heart health, may not have an immediate impact on lowering blood pressure compared to reducing sodium intake.

3. While assessing a client receiving a blood transfusion, which finding requires immediate intervention?

• A. Temperature of 100.4°F (38°C).
• B. Blood pressure of 110/70 mm Hg.
• C. Heart rate of 90 beats per minute.
• D. Complaints of feeling cold.

Correct answer: C

Rationale: A heart rate of 90 beats per minute requires immediate intervention when assessing a client receiving a blood transfusion. This finding can indicate a potential transfusion reaction, such as a hemolytic reaction or fluid overload, which requires prompt evaluation and management to prevent serious complications. While a temperature of 100.4°F (38°C) may indicate a mild fever, it is not typically an immediate concern during a blood transfusion. A blood pressure of 110/70 mm Hg is within the normal range and does not necessitate immediate intervention. Complaints of feeling cold can be addressed but do not indicate an urgent need for intervention compared to the critical nature of a potential transfusion reaction indicated by an elevated heart rate.

4. During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?

• A. Call the pharmacy to determine what medications she is taking
• B. Seek the family's assistance in taking care of the client
• C. Complete a physical and mental exam on the client
• D. Call the adult protective services to obtain emergency nursing home placement

Correct answer: C

Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.

5. The nurse is providing discharge teaching to a client with a new colostomy. Which statement by the client indicates a need for further teaching?

• A. I will avoid foods that cause gas.
• B. I will change my colostomy bag every week.
• C. I will use a skin barrier to protect the skin around the stoma.
• D. I will empty my colostomy bag when it is one-third full.

Correct answer: B

Rationale: The correct answer is B. Changing the colostomy bag every week is not sufficient; it should be changed more frequently to prevent leakage and skin irritation. Option A is correct as avoiding foods that cause gas can help manage colostomy-related symptoms. Option C is correct as using a skin barrier helps protect the skin around the stoma. Option D is correct as emptying the colostomy bag when it is one-third full helps prevent leakage and discomfort.

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