Nursing Elites

1. The nurse is caring for a client following a craniotomy. Which finding should the nurse report immediately?

• A. Pupils equal and reactive to light.
• B. Sudden increase in urine output.
• C. Diminished breath sounds bilaterally.
• D. Increase in blood pressure by 20 mmHg.

Correct answer: C

Rationale: The correct answer is C, 'Diminished breath sounds bilaterally.' This finding should be reported immediately as it could indicate a serious complication such as increased intracranial pressure or respiratory compromise. In a post-craniotomy client, changes in breath sounds may be a sign of developing issues that need prompt intervention. Choices A, B, and D are not as critical in the immediate post-craniotomy period. Pupils equal and reactive to light are expected findings, a sudden increase in urine output may require monitoring but not immediate reporting, and a small increase in blood pressure may not be alarming unless it is significantly high or accompanied by other concerning signs.

2. A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?

• A. Limit sodium intake to 2 grams per day.
• B. Choose fresh fruits and vegetables.
• C. Drink at least 8 glasses of water daily.
• D. Avoid processed foods and canned soups.

Correct answer: D

Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.

3. Which intervention should the nurse include in the care plan for a child with tetanus?

• A. Ensure proper hydration
• B. Administer prescribed antibiotics
• C. Monitor vital signs frequently
• D. Minimize the amount of stimuli in the room

Correct answer: D

Rationale: The correct intervention for a child with tetanus is to minimize the amount of stimuli in the room. Tetanus causes severe muscle spasms and sensitivity to stimuli, so reducing stimuli like light, sound, and touch can help prevent painful spasms. While ensuring proper hydration and administering antibiotics are essential components of care, minimizing stimuli is crucial for the child's comfort and safety as it directly addresses the symptoms associated with tetanus.

4. A client with gastroesophageal reflux disease (GERD) is prescribed omeprazole. What is the primary purpose of this medication?

• A. Coat the lining of the stomach
• B. Neutralize stomach acid
• C. Promote gastric motility
• D. Reduce gastric acid secretion

Correct answer: D

Rationale: The correct answer is D: Reduce gastric acid secretion. Omeprazole is a proton pump inhibitor that works by reducing the production of gastric acid in the stomach. This helps in managing GERD by decreasing the acidity levels in the stomach. Choice A is incorrect because omeprazole does not coat the lining of the stomach. Choice B is incorrect as omeprazole does not neutralize stomach acid but rather reduces its production. Choice C is incorrect because omeprazole does not promote gastric motility; instead, it acts on acid secretion.

5. A client with chronic kidney disease is receiving erythropoietin injections. What laboratory value should the nurse monitor to evaluate the effectiveness of the treatment?

• A. Serum potassium
• B. Hemoglobin
• C. White blood cell count
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Hemoglobin. Erythropoietin stimulates the production of red blood cells, leading to an increase in hemoglobin levels. Monitoring hemoglobin is crucial to assess the effectiveness of the treatment. Choices A, C, and D are incorrect. Serum potassium levels are often monitored in chronic kidney disease, but it is not the primary parameter to evaluate the effectiveness of erythropoietin therapy. White blood cell count and platelet count are not directly influenced by erythropoietin injections for chronic kidney disease.

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