Nursing Elites

1. A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?

• A. Facial puffiness and periorbital edema
• B. Hematocrit of 30%
• C. Cold and dry skin
• D. Further decline in LOC

Correct answer: D

Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.

2. A young female client with 7 children is having frequent morning headaches, dizziness, and blurred vision. Her BP is 168/104. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV med, which intervention is most important for the nurse to implement?

• A. Measure urine output hourly to assess for renal perfusion
• B. Request a prescription for pain medication
• C. Use an automated BP machine to monitor for hypotension
• D. Provide a quiet environment with low lighting

Correct answer: C

Rationale: Using an automated BP machine is crucial to continuously monitor for hypotension after administering an antihypertensive medication. This is essential to prevent a rapid drop in blood pressure that could lead to complications. Measuring urine output hourly to assess for renal perfusion is important but not the most immediate concern in this situation. Requesting pain medication is not relevant to the primary issue of managing blood pressure. Providing a quiet environment with low lighting may be beneficial for the client's overall well-being but is not as critical as monitoring for potential hypotension.

3. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. When is the child no longer contagious?

• A. When the fever dissipates
• B. After the incubation period
• C. When the lesions have healed
• D. When the lesions are crusted over

Correct answer: D

Rationale: The correct answer is D: 'When the lesions are crusted over.' Varicella is no longer contagious once the lesions are dry and crusted. This stage indicates that the active viral shedding has significantly decreased, reducing the risk of transmission. Choice A, 'When the fever dissipates,' is incorrect because the presence of fever does not necessarily correlate with the contagiousness of varicella. Choice B, 'After the incubation period,' is incorrect as the incubation period occurs before the onset of symptoms and is not relevant to determining contagiousness. Choice C, 'When the lesions have healed,' is incorrect as healed lesions can still be contagious if they are not crusted over.

4. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

5. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

• A. Document the client's report of pain in the electronic medical record.
• B. Determine which prescription will have the quickest onset of action.
• C. Compare the client's pain scale rating with the prescribed dosing.
• D. Ask the client to choose which medication is needed for the pain.

Correct answer: C

Rationale: The correct action the nurse should implement before selecting which medication to administer to a postoperative client who reports incisional pain is to compare the client's pain scale rating with the prescribed dosing. This ensures that the client receives the appropriate medication based on their pain level. Documenting the client's report of pain in the electronic medical record (Choice A) is important but should come after ensuring the right medication is given. Determining which prescription will have the quickest onset of action (Choice B) may not be the most relevant factor to consider when choosing the appropriate medication. Asking the client to choose the medication needed for the pain (Choice D) may not be appropriate as the nurse should rely on the pain scale rating and prescribed dosing to make a clinical decision.

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