Nursing Elites

1. What is the first step in assessing a patient with suspected stroke?

• A. Check for facial droop
• B. Assess speech clarity
• C. Perform a neurological assessment
• D. Call for emergency assistance

Correct answer: D

Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.

2. A nurse is collecting data from a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage for the client
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: The correct action the nurse should take first when noting excessive lochia discharge in a client who delivered a full-term newborn 16 hours ago is to perform a fundal massage. Fundal massage helps stimulate uterine contractions, which in turn reduces bleeding in postpartum clients. Administering pain medication (Choice A) is not the priority in this situation as addressing the excessive lochia discharge is crucial to prevent complications. Checking the baby's heart rate (Choice C) is important but not the first action to manage the mother's condition. Applying an ice pack (Choice D) is not appropriate for managing excessive lochia discharge; fundal massage is the initial intervention to address this issue effectively.

3. A client with active tuberculosis is receiving discharge instructions. Which statement by the client indicates an understanding of the teaching?

• A. I will continue taking my isoniazid until I am no longer contagious.
• B. I should take my prescribed medication for at least 6 months.
• C. I will need to have a TB skin test every 3 months.
• D. I should wear a mask at all times.

Correct answer: B

Rationale: The correct answer is B because the client should take antitubercular medications for a minimum of 6 months to ensure complete eradication of the infection. Choice A is incorrect as stopping the medication early can result in treatment failure and development of drug-resistant TB. Choice C is incorrect as regular TB skin tests are not needed once the client has been diagnosed and treated. Choice D is incorrect as wearing a mask at all times is not necessary for a client with active TB; proper cough etiquette should be followed instead.

4. What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?

• A. Apply a cold compress
• B. Notify the physician immediately
• C. Apply a warm compress
• D. Administer anti-inflammatory medication

Correct answer: C

Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.

5. What are the early signs of heart failure in a patient?

• A. Shortness of breath and weight gain
• B. Fatigue and chest pain
• C. Nausea and vomiting
• D. Cough and elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. Early signs of heart failure typically manifest as shortness of breath due to fluid accumulation in the lungs and weight gain due to fluid retention in the body. Choices B, C, and D are incorrect. Fatigue and chest pain are symptoms commonly associated with heart conditions but are not specific early signs of heart failure. Nausea and vomiting are not typically early signs of heart failure. Cough can be a symptom of heart failure, but it is usually associated with other symptoms like shortness of breath rather than being an isolated early sign. Elevated blood pressure is not an early sign of heart failure; in fact, heart failure is more commonly associated with low blood pressure.

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