Nursing Elites

1. A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

• A. Position the head of the bed (HOB) flat.
• B. Withhold intravenous fluids.
• C. Administer a bolus of IV fluids.
• D. Give an antihypertensive medication.

Correct answer: D

Rationale: In a client with a completed ischemic stroke, an elevated blood pressure like 180/90 mm Hg requires immediate intervention to prevent further damage. Giving an antihypertensive medication is essential to reduce the risk of recurrent stroke or complications related to hypertension. Positioning the head of the bed flat, withholding IV fluids, or administering a bolus of IV fluids are not appropriate actions for managing elevated blood pressure in this scenario and may not address the underlying cause of the hypertension or prevent potential complications.

2. A client recovering from extracorporeal shock wave lithotripsy for renal calculi has an ecchymotic area on the right lower back. What action should the nurse take?

• A. Administer fresh-frozen plasma.
• B. Apply an ice pack to the site.
• C. Place the client in the prone position.
• D. Obtain serum coagulation test results.

Correct answer: B

Rationale: After extracorporeal shock wave lithotripsy, ecchymosis can occur due to bleeding into the tissues from the shock waves. Applying an ice pack helps reduce the extent and discomfort of bruising. Administering fresh-frozen plasma and obtaining coagulation test results are not necessary as ecchymosis after this procedure is common and does not indicate a bleeding disorder that requires immediate intervention. Placing the client in the prone position will not address the bleeding or bruising in this situation.

3. When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?

• A. Recommend that the client carry suction equipment at all times.
• B. Instruct the client to have writing materials with them at all times.
• C. Tell the client to carry a medic alert card stating that they are a total neck breather.
• D. Tell the client not to travel alone.

Correct answer: C

Rationale: The most crucial instruction for a client who has had a total laryngectomy is to carry a medic alert card stating that they are a total neck breather. This is important because if they experience a cardiac arrest, mouth-to-neck breathing may be required. Choice A about carrying suction equipment is not the most critical as the client may not always need it. Choice B is not as essential as having a medic alert card. Choice D is not directly related to the client's safety due to their laryngectomy.

4. A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client’s fluid balance is stable at this time?

• A. Decreased calcium levels
• B. Increased phosphorus levels
• C. No adventitious sounds in the lungs
• D. Increased edema in the legs

Correct answer: C

Rationale: The absence of adventitious sounds upon auscultation of the lungs is a key indicator that the client's fluid balance is stable. Adventitious sounds, such as crackles or wheezes, are typically heard in conditions of fluid overload, indicating that the body is retaining excess fluid. Choices A and B, decreased calcium levels and increased phosphorus levels, are common laboratory findings associated with chronic kidney disease (CKD) and are not directly related to fluid balance. Increased edema in the legs is a sign of fluid imbalance, suggesting fluid retention in the tissues, which would not indicate stable fluid balance in a client with CKD on fluid restrictions.

5. After confirming that liquids are allowed, which assessment action should the nurse consider a priority for a client who is fully awake after a gastroscopy?

• A. Listen to bilateral lung and bowel sounds.
• B. Obtain the client's pulse and blood pressure.
• C. Assist the client to the bathroom to void.
• D. Check the client's gag and swallow reflexes.

Correct answer: D

Rationale: After a gastroscopy, it is crucial for the nurse to prioritize checking the client's gag and swallow reflexes before allowing them to drink anything. This is because the effects of local anesthesia need to dissipate, and the airway's protective reflexes, including the gag and swallow reflexes, must have returned to prevent aspiration. Listening to lung and bowel sounds (Choice A) may be important but does not take precedence over ensuring the client's safety post-gastroscopy. Obtaining the client's pulse and blood pressure (Choice B) is also important but not the priority in this scenario. Assisting the client to the bathroom to void (Choice C) is a routine nursing action and is not directly related to the immediate safety concern of checking the client's gag and swallow reflexes post-gastroscopy.

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