Nursing Elites

1. The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading?

• A. Frequent syncope
• B. Muscle rigidity
• C. Gait instability
• D. Fine motor tremors

Correct answer: A

Rationale: The correct answer is A: 'Frequent syncope.' Orthostatic hypotension, common in Parkinson's disease, often causes syncope (fainting) when blood pressure drops upon standing. This information is critical for planning safe blood pressure measurements, ensuring readings are taken in both lying and standing positions to assess for sudden drops in pressure. Muscle rigidity, tremors, or gait instability are important symptoms in Parkinson's disease but are not directly related to blood pressure assessment.

2. 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.

3. A client admitted with left-sided heart failure presents with shortness of breath and pink frothy sputum. Which assessment finding requires immediate intervention?

• A. Decreased breath sounds bilaterally.
• B. Heart rate of 110 bpm and irregular rhythm.
• C. Pink frothy sputum and increased respiratory rate.
• D. Elevated blood pressure and shortness of breath.

Correct answer: C

Rationale: Correct Answer: Pink frothy sputum and increased respiratory rate. Pink frothy sputum is a sign of pulmonary edema, indicating fluid in the lungs, a life-threatening condition that requires immediate intervention to prevent respiratory failure. Increased respiratory rate is also concerning as it indicates the body's effort to compensate for the decreased oxygenation. Options A, B, and D are not the most critical findings in this situation. Decreased breath sounds bilaterally may indicate a pneumothorax or atelectasis, heart rate of 110 bpm and irregular rhythm can be managed with medications and further assessment, and elevated blood pressure with shortness of breath is not as urgent as pink frothy sputum and increased respiratory rate.

4. A young male client with an above-knee amputation (AKA) reports that his 'right foot is aching.' What is the most important intervention for the nurse to implement?

• A. Encourage discussion of feelings about the loss of his limb.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer to assist the client to a quieter location to relax.

Correct answer: B

Rationale: The correct answer is B because gabapentin is prescribed to treat phantom limb pain, which is common in individuals with amputations. Option A is not the most important intervention at this time since the client is reporting physical pain, not emotional distress. Option C is not appropriate because the client is reporting aching in the foot, not the stump. Option D does not address the underlying issue of phantom limb pain that needs to be managed.

5. A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?

• A. Auscultate the bowel sounds.
• B. Palpate the ankles for edema.
• C. Observe the skin for bruising.
• D. Measure the body temperature.

Correct answer: A

Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.

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