Nursing Elites

1. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

• A. Call a code immediately
• B. Assess the client for a pulse
• C. Begin chest compressions
• D. Continue to monitor the client

Correct answer: B

Rationale: The correct first intervention when a client goes into ventricular tachycardia is to assess for a pulse. This is crucial as the presence or absence of a pulse guides subsequent actions. Initiating chest compressions or calling a code should only be done after confirming the absence of a pulse. Continuing to monitor the client without checking for a pulse delays potentially life-saving interventions.

2. During a physical assessment of a newborn, what finding should the nurse prioritize reporting?

• A. Head circumference of 40 cm
• B. Chest circumference of 32 cm
• C. Acrocyanosis and edema of the scalp
• D. Heart rate of 160 bpm and respirations of 40/min

Correct answer: A

Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.

3. Which of the following is a primary factor that affects blood pressure?

• A. Obesity
• B. Age
• C. Stress
• D. Gender

Correct answer: A

Rationale: Obesity is a primary factor that affects blood pressure. Excess body weight, especially when concentrated around the abdomen, can increase the risk of hypertension (high blood pressure) as it puts extra strain on the heart to pump blood around the body. This can lead to various cardiovascular complications and other health issues. Managing weight through a healthy diet and regular physical activity can help control blood pressure levels. Age, stress, and gender can also influence blood pressure but are not primary factors like obesity.

4. After a pericardiocentesis, what interventions should the nurse implement?

• A. Monitor vital signs every 15 minutes for the first hour
• B. Evaluate the client’s cardiac rhythm
• C. Record the amount of fluid removed as output
• D. All of the above

Correct answer: D

Rationale: After a pericardiocentesis, the nurse should implement multiple interventions to monitor the client's condition closely. Monitoring vital signs every 15 minutes for the first hour is crucial to detect any immediate changes that may indicate complications. Evaluating the client's cardiac rhythm is important to identify any arrhythmias that may occur due to the procedure. Recording the amount of fluid removed is essential to calculate fluid balance and ensure accurate monitoring of the client's status. Therefore, all the interventions mentioned are necessary to detect and manage any potential issues post-pericardiocentesis. Choices A, B, and C are all essential components of post-procedural care and should be implemented to ensure the client's safety and well-being.

5. The nurse is planning to provide education about foods containing thiamine to a group of clients. Which food high in thiamine should the nurse include?

• A. Fish
• B. Pork
• C. Beef
• D. Eggs

Correct answer: B

Rationale: The correct answer is B: Pork. Pork is high in thiamine, which is important for preventing thiamine deficiency. Thiamine, also known as vitamin B1, is essential for the proper functioning of the nervous system and metabolism. While fish, beef, and eggs are nutritious foods, they are not as high in thiamine as pork. Fish is more commonly known for its omega-3 fatty acids, beef for its iron content, and eggs for being a good source of protein and other nutrients.

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