Nursing Elites

1. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

2. A young adult client is receiving instruction from a healthcare provider about health promotion and illness prevention. Which of the following statements indicates understanding?

• A. “I had my immunizations as a child, so I’m protected in that area.”
• B. “It is important to schedule routine health care visits even if I am feeling well.”
• C. “I will go to an urgent care center for my routine medical care.”
• D. “There’s no reason to seek help if I am feeling stressed as it’s just part of life.”

Correct answer: B

Rationale: The correct answer is B. Scheduling routine health care visits, even when feeling well, is crucial for early detection and prevention of health issues. This proactive approach allows healthcare providers to monitor overall health, provide preventive care, and address any emerging health concerns promptly. Choice A is incorrect because past immunizations do not cover all potential diseases; regular check-ups are still necessary. Choice C is incorrect as urgent care centers are not designed for routine medical care. Choice D is incorrect as seeking help for stress is important for mental well-being and should not be dismissed as a normal part of life.

3. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

• A. Check the catheter to see whether it is patent.
• B. Reassure the client that it is not possible for them to urinate.
• C. Re-catheterize the bladder with a larger-gauge catheter.
• D. Collect a urine specimen for analysis.

Correct answer: A

Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.

4. A client with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?

• A. Airborne precautions
• B. Droplet precautions
• C. Contact precautions
• D. Compromised host precautions

Correct answer: C

Rationale: Contact precautions are necessary when performing postmortem care on a client with MRSA to prevent the spread of infection. Contact precautions involve using barriers like gloves and gowns to limit direct contact with the deceased individual's body fluids and tissues. Airborne precautions are used for pathogens that are transmitted through the air, like tuberculosis. Droplet precautions are for pathogens that are transmitted through respiratory droplets, such as influenza. Compromised host precautions are not a recognized standard precaution type and are not applicable in this scenario.

5. While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?

• A. Albumin level of 3 g/dL
• B. Hemoglobin level of 12 g/dL
• C. WBC count of 6,000/mm³
• D. Blood glucose level of 100 mg/dL

Correct answer: A

Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.

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