Nursing Elites

1. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

• A. Heart rate
• B. Pedal pulses
• C. Lung sounds
• D. Pupil responses

Correct answer: D

Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.

2. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?

• A. Avoid chocolate and cheese
• B. Take frequent naps
• C. Take the medication with milk
• D. Avoid walking without assistance

Correct answer: A

Rationale: The correct answer is to avoid chocolate and cheese. MAO inhibitors can interact with tyramine-rich foods like these, potentially leading to severe hypertension. Choices B, C, and D are incorrect because taking frequent naps, taking the medication with milk, and avoiding walking without assistance are not relevant precautions associated with MAO inhibitors.

3. A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: The correct answer is to assess for dyspnea or stridor. In burn cases involving the face, neck, or chest, there is a risk of airway compromise due to swelling. Dyspnea (difficulty breathing) or stridor (noisy breathing) can indicate airway obstruction or respiratory distress, which requires immediate intervention. Covering the burns with dry sterile dressings (choice A) can be important but ensuring airway patency takes precedence. Initiating intravenous therapy (choice C) may be necessary but not the priority over assessing the airway. Administering pain medication (choice D) is important for comfort but should come after ensuring the airway is clear and breathing is adequate.

4. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?

• A. Obtain a 12-lead EKG
• B. Place the client in high Fowler's position
• C. Lower the oxygen rate
• D. Take baseline vital signs

Correct answer: C

Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.

5. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?

• A. Sedative hypnotics are effective analgesics
• B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
• C. Caffeine beverages can increase the effect of sedative hypnotics
• D. Avoidance of excessive exercise and high temperature is recommended

Correct answer: B

Rationale: The correct answer is B. Alprazolam should not be stopped abruptly as it can cause rebound insomnia and nightmares; gradual tapering is necessary. Choice A is incorrect as sedative hypnotics are not primarily used as analgesics. Choice C is incorrect as caffeine can decrease the effects of sedative hypnotics rather than increase them. Choice D is incorrect as there is no specific recommendation to avoid excessive exercise or high temperature related to alprazolam use.

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