Nursing Elites

1. A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 90 beats per minute
• B. A blood pressure of 120/80 mm Hg
• C. A respiratory rate of 16 breaths per minute
• D. A temperature of 98.6 degrees Fahrenheit

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.

2. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: When the high-pressure alarm on a ventilator goes off, the nurse's initial action should be to perform a quick assessment of the client's condition. This assessment helps in promptly identifying the cause of the alarm, such as mucus plugging, kinking of the tubing, or other issues. By assessing the client first, the nurse can determine the appropriate intervention needed to address the alarm. Choices A and D are incorrect because disconnecting the client from the ventilator or pressing the alarm reset button should not be the initial actions without assessing the client's condition. While calling the respiratory therapist for help could be beneficial, assessing the client's condition should be the nurse's priority to address the immediate concern.

3. The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?

• A. We will call the healthcare provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occurs.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.

4. A client is receiving teaching about a high-fiber diet to manage constipation. Which statement indicates the best choice for a high-fiber diet?

• A. Eating one medium apple is a good snack option.
• B. Selecting a ½ cup of sweet potatoes for starch is a great choice.
• C. Choosing a ½ cup of bran cereal for breakfast is ideal.
• D. Opting for 1 ounce of almonds when hungry midday is recommended.

Correct answer: C

Rationale: The correct answer is C because bran cereal is a high-fiber food that can effectively alleviate constipation by promoting regular bowel movements. Option A, an apple, while a healthy snack, may not provide as much fiber as bran cereal. Option B, sweet potatoes, are nutritious but may not be as high in fiber as bran cereal. Option D, almonds, are a good source of healthy fats and protein but do not provide as much fiber as bran cereal.

5. The healthcare provider should recognize which of the following as an indication of dehydration in an elderly client?

• A. Skin turgor
• B. Dry mucous membranes
• C. Elevated temperature
• D. Increased pulse pressure

Correct answer: B

Rationale: Dry mucous membranes are a classic sign of dehydration, especially in elderly individuals. Dehydration can lead to decreased moisture in the mucous membranes, making them dry. Skin turgor, although commonly assessed for dehydration in younger individuals, may be less reliable in the elderly due to changes in skin elasticity. Elevated temperature is more indicative of an infection or other conditions. Increased pulse pressure is not typically associated with dehydration in the elderly.

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