Nursing Elites

1. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?

• A. A heart rate of 72 beats per minute
• B. A blood pressure of 110/70 mm Hg
• C. Pupils equal and reactive to light
• D. Client reports headache

Correct answer: C

Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.

2. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

3. A nurse is reinforcing teaching with a client about dietary choices for celiac disease. Which of the following menu choices selected by the client indicates an understanding of the teaching?

• A. Hamburger on a wheat bun
• B. Baked chicken and potato chips
• C. Bacon, lettuce, and tomato sandwich on rye toast
• D. Beef and barley soup with crackers

Correct answer: B

Rationale: The correct answer is B because baked chicken and potato chips are gluten-free options suitable for a client with celiac disease. Choice A, a hamburger on a wheat bun, contains gluten, which is harmful to individuals with celiac disease. Choice C, a bacon, lettuce, and tomato sandwich on rye toast, also contains gluten. Choice D, beef and barley soup with crackers, includes gluten from the barley and crackers, making it unsuitable for someone with celiac disease.

4. A client is being treated for tuberculosis (TB). Which of these statements indicates the client understands the transmission of TB?

• A. I need to wear a mask when I go out in public to prevent spreading the infection.
• B. I need to take my medication as prescribed to prevent spreading the infection to others.
• C. I need to cover my mouth when I cough to prevent spreading the infection.
• D. I need to isolate myself from others until my treatment is complete to prevent spreading the infection.

Correct answer: A

Rationale: The correct answer is A because wearing a mask in public can help prevent the spread of TB to others. Choice B is incorrect as taking medication as prescribed helps in treating the infection within the individual but does not directly prevent spreading it to others. Choice C is important for respiratory hygiene but may not be sufficient to prevent transmission. Choice D, isolation until treatment is complete, is crucial for preventing the spread but is not specifically about understanding transmission.

5. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

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