Nursing Elites

1. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

2. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Elevated blood pressure.
• C. Furrows in the tongue.
• D. Polyuria.

Correct answer: C

Rationale: The correct answer is C: 'Furrows in the tongue.' Dehydration commonly presents with furrows in the tongue due to decreased oral moisture. This physical finding indicates dehydration as the tongue loses moisture and becomes dry. Choice A, 'Bradycardia,' is not typically associated with dehydration; instead, tachycardia may be present as a compensatory mechanism. Elevated blood pressure, as mentioned in choice B, is not a typical finding in dehydration; in fact, dehydration often leads to a decrease in blood pressure. Polyuria, as in choice D, is more commonly associated with conditions like diabetes mellitus or diabetes insipidus, rather than dehydration.

3. When should a healthcare provider suction a client's tracheostomy?

• A. When the client is hypotensive
• B. When the client is irritable
• C. When the client is flushed
• D. When the client is bradycardic

Correct answer: B

Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.

4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

• A. Shave hairy areas of skin prior to application.
• B. Wear gloves to apply the patch to the client's skin.
• C. Apply the patch within 1 hr of removing it from the protective pouch.
• D. Remove the previous patch and place it in a tissue.

Correct answer: B

Rationale: The correct answer is to wear gloves when applying the transdermal nicotine patch to prevent the nurse from absorbing nicotine through the skin. Choice A is incorrect because shaving hairy areas of skin is not necessary for applying a transdermal patch. Choice C is incorrect as transdermal patches should be applied immediately after removal from the protective pouch, not necessarily within 1 hour. Choice D is incorrect because the previous patch should be disposed of properly following institutional guidelines, not placed in a tissue.

5. What are the key components of a focused respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Observation, Percussion, Auscultation, Palpation
• C. Auscultation, Palpation, Observation, Percussion
• D. Palpation, Inspection, Auscultation, Percussion

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for any abnormalities, palpating to assess tenderness and chest expansion, percussion to evaluate underlying structures, and auscultation to listen to lung sounds. Choice B is incorrect because observation is generally part of inspection, not a separate component. Choice C is incorrect as auscultation should come before percussion in a respiratory assessment. Choice D is incorrect because inspection should precede palpation in a structured assessment.

Similar Questions