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. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

• A. Protect the skin of the radiation portal site from sunlight exposure
• B. Apply moisturizing lotions daily to the radiation portal site
• C. Avoid washing the skin inside the radiation portal site
• D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

3. The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?

• A. Auscultate the pulses with a stethoscope.
• B. Call the physician.
• C. Use a Doppler ultrasound device.
• D. Inspect the lower left extremity.

Correct answer: C

Rationale: When pedal pulses are not palpable, using a Doppler ultrasound device is the appropriate next step to locate the pulse. Auscultating the pulses with a stethoscope (Choice A) is used for assessing blood flow in arteries above the clavicle, not for pedal pulses. Calling the physician (Choice B) may be necessary at a later stage, but initially, using a Doppler ultrasound device to locate the pulse is more appropriate. Inspecting the lower left extremity (Choice D) can provide visual information but will not help in locating the pedal pulses, making it a less suitable option.

4. The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?

• A. Clear dialysate outflow.
• B. Cloudy dialysate outflow.
• C. Decreased urine output.
• D. Increased blood pressure.

Correct answer: B

Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.

5. After the administration of t-PA, what should the nurse do?

• A. Observe the client for chest pain.
• B. Monitor for fever.
• C. Review the 12-lead electrocardiogram (ECG).
• D. Auscultate breath sounds.

Correct answer: A

Rationale: After the administration of t-PA, the nurse should observe the client for chest pain. Chest pain post t-PA administration could indicate reocclusion of the coronary artery, a serious complication that requires immediate intervention. Monitoring for fever (choice B) is not specifically associated with t-PA administration. While reviewing the 12-lead ECG (choice C) is important for assessing cardiac function, it may not be the immediate priority right after t-PA administration. Auscultating breath sounds (choice D) is important for assessing respiratory status but is not the most crucial assessment following t-PA administration.

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