Nursing Elites

1. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?

• A. Client reports dizziness
• B. Client has a drop in blood pressure
• C. Client experiences mild nausea
• D. Client reports dry mouth

Correct answer: B

Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.

2. A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?

• A. Monitor for clear fluid leakage from the nose.
• B. Assess for rapid onset of decreased level of consciousness.
• C. Check for bruising around the head and neck.
• D. Assess for changes in pupil size and reactivity.

Correct answer: B

Rationale: An epidural hematoma is characterized by a rapid onset of symptoms, including decreased level of consciousness, due to arterial bleeding, which differentiates it from other types of intracranial hemorrhage. Monitoring for clear fluid leakage from the nose (choice A) is more indicative of a basilar skull fracture and cerebrospinal fluid leak. Checking for bruising around the head and neck (choice C) is more suggestive of soft tissue injuries or facial fractures. Assessing for changes in pupil size and reactivity (choice D) is essential in evaluating traumatic brain injuries, but it is not specific to differentiating the vascular source of intracranial bleeding in an epidural hematoma.

3. The nurse is preparing a client who had a BKA amputation for discharge to home. Which recommendations should the nurse provide this client?

• A. All of the above
• B. Inspect the skin for redness
• C. Use a residual limb shrinker
• D. Wash the stump with soap and water

Correct answer: A

Rationale: Proper care of the residual limb is essential in preventing complications like infection or poor healing. By choosing 'All of the above,' the nurse ensures that the client receives comprehensive care. Inspecting the skin for redness is crucial as it can help in early detection of infections. Using a residual limb shrinker helps reduce swelling and maintain proper shaping of the limb. Washing the stump with soap and water on a daily basis is important for hygiene and preventing infections. Therefore, all the recommendations (choices A, B, and C) are essential for the client's care, making choice A the correct answer. Choice D is incorrect as it does not encompass all the necessary recommendations for the client's care.

4. Which client is at greatest risk for developing delirium?

• A. An adult client who cannot sleep due to pain.
• B. An older client who attempted suicide 1 month ago.
• C. A young adult taking antipsychotic medications twice daily.
• D. A middle-aged woman using supplemental oxygen.

Correct answer: B

Rationale: The correct answer is B. Older adults who have attempted suicide are at higher risk for developing delirium, especially in the context of underlying mental health conditions. Choice A is incorrect as sleep disturbances due to pain may lead to discomfort but not necessarily delirium. Choice C is incorrect as taking antipsychotic medications, if managed well, does not inherently increase the risk of delirium. Choice D is incorrect as using supplemental oxygen alone does not significantly increase the risk of developing delirium.

5. The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?

• A. Bananas
• B. Processed meats
• C. Low-fat yogurt
• D. Whole grains

Correct answer: B

Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.

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