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. After undergoing a renal biopsy, a client reports pain radiating to the front of the abdomen from the biopsy site. What finding should the nurse assess the client for?

• A. Bleeding
• B. Renal colic
• C. Infection at the site
• D. Increased temperature

Correct answer: A

Rationale: The correct answer is A: Bleeding. Pain radiating to the front of the abdomen from the renal biopsy site suggests bleeding, which should be promptly assessed and managed. Bleeding can lead to serious complications if not addressed timely. Renal colic (choice B) is associated with kidney stones and typically presents with severe flank pain. Infection at the site (choice C) would more likely present with localized signs such as redness, swelling, warmth, and tenderness. Increased temperature (choice D) alone is not specific to the issue described and may be indicative of various conditions.

3. Upon arrival of a client transferred to the surgical unit, what should the nurse plan to do first?

• A. Assess the patency of the airway
• B. Check tubes and drains for patency
• C. Check the dressing for bleeding
• D. Assess the vital signs to compare them with preoperative measurements

Correct answer: A

Rationale: The initial action for the nurse upon the arrival of a client to the surgical unit is to assess the patency of the airway. This step takes priority to ensure that the client has a clear airway for adequate breathing. Checking tubes and drains for patency, inspecting the dressing for bleeding, and assessing vital signs to compare with preoperative measurements are important subsequent steps in the assessment process. However, ensuring the airway is patent is the immediate priority to maintain the client's respiratory function and overall well-being.

4. The nurse is preparing to give a dose of a cephalosporin medication to a patient who has been receiving the antibiotic for 2 weeks. The nurse notes ulcers on the patient’s tongue and buccal mucosa. Which action will the nurse take?

• A. Hold the drug and notify the provider.
• B. Obtain an order to culture the oral lesions.
• C. Gather emergency equipment to prepare for anaphylaxis.
• D. Report a possible superinfection side effect of the cephalosporin.

Correct answer: D

Rationale: The nurse should report a possible superinfection side effect of the cephalosporin to the physician as the patient's symptoms may indicate a superinfection that requires treatment. Holding the drug is not necessary unless directed by the provider. Culturing the lesions is not indicated for this situation. There is no evidence to suggest impending anaphylaxis based on the patient's symptoms.

5. Which of the following is a key symptom of hyperthyroidism?

• A. Weight loss.
• B. Weight gain.
• C. Tachycardia.
• D. Dry skin.

Correct answer: A

Rationale: The correct answer is weight loss. In hyperthyroidism, there is an excess production of thyroid hormones leading to an increased metabolic rate. This increased metabolism can result in weight loss despite normal or increased appetite. Choice B (Weight gain) is more commonly associated with hypothyroidism where the metabolic rate is decreased. Choice C (Tachycardia) is another common symptom of hyperthyroidism due to the effects of thyroid hormones on the heart, causing an increased heart rate. Choice D (Dry skin) is not a typical symptom of hyperthyroidism; instead, it is more commonly associated with hypothyroidism.

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