Nursing Elites

1. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow Coma Scale (GCS) every two hours. For the past 8 hours, the client's GCS score has been 14. What does this GCS finding indicate about the client?

• A. Neurologically stable without indications of increased ICP.
• B. At risk for neurological deterioration.
• C. Experiencing mild cognitive impairment.
• D. In need of immediate medical intervention.

Correct answer: A

Rationale: A GCS score of 14 indicates that the client is neurologically stable without indications of increased ICP. It suggests that the client's neurological status is relatively intact, with only mild impairment, if any. This finding reassures the nurse that there are currently no signs of deterioration or immediate need for intervention. Choice B is incorrect because a GCS score of 14 does not necessarily indicate immediate risk for neurological deterioration. Choice C is incorrect as mild cognitive impairment is not typically inferred from a GCS score of 14. Choice D is incorrect as immediate medical intervention is not warranted based on a GCS score of 14 without other concerning symptoms.

2. A client with a history of hypertension is admitted with shortness of breath and chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Pulmonary function tests (PFTs)
• D. Arterial blood gases (ABGs)

Correct answer: A

Rationale: The correct answer is A: Electrocardiogram (ECG). An ECG should be performed first to assess for cardiac ischemia in a client presenting with shortness of breath and chest pain. This test helps in evaluating the electrical activity of the heart and can identify signs of myocardial infarction or other cardiac issues. Choice B, Chest X-ray, may be ordered after the ECG to assess for pulmonary conditions like pneumonia or effusions. Choice C, Pulmonary function tests (PFTs), are used to evaluate lung function and are not the primary diagnostic tests for a client with symptoms of cardiac origin. Choice D, Arterial blood gases (ABGs), may provide information about oxygenation but are not the initial test indicated for a client with suspected cardiac issues.

3. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor (ACEI). Which instruction should the nurse include in the medication teaching plan?

• A. Increase intake of potassium-rich foods
• B. Report increased bruising or bleeding
• C. Stop medication if a cough develops
• D. Limit intake of leafy green vegetables

Correct answer: B

Rationale: The correct instruction for the nurse to include in the medication teaching plan for a client receiving enalapril, an ACE inhibitor, is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which can lead to an increased risk of bruising and bleeding. Monitoring and reporting these symptoms promptly are essential to prevent complications. Choices A, C, and D are incorrect because increasing potassium-rich foods, stopping medication if a cough develops, and limiting intake of leafy green vegetables are not directly related to the common side effects or actions of ACE inhibitors.

4. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider before the procedure?

• A. Serum potassium of 5.5 mEq/L
• B. Hemoglobin of 10 g/dl
• C. Potassium of 6.0 mEq/L
• D. Blood glucose of 200 mg/dl

Correct answer: C

Rationale: The correct answer is C: Potassium of 6.0 mEq/L. A potassium level of 6.0 mEq/L is dangerously high in a client with CKD, and it should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Choices A, B, and D are not the most critical values to report before hemodialysis. While a serum potassium level of 5.5 mEq/L is slightly elevated, it is not as urgent as a level of 6.0 mEq/L in this context. Hemoglobin of 10 g/dl and blood glucose of 200 mg/dl are important parameters to monitor but are not as immediately concerning before hemodialysis compared to a high potassium level.

5. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?

• A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
• B. Stop the NGT feed and notify the healthcare provider
• C. Increase the NGT suction pressure
• D. Elevate the head of the bed

Correct answer: A

Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.

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