Nursing Elites

1. A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?

• A. Monitor the site for further complications.
• B. Promptly remove the catheter from the radial artery.
• C. Elevate the client’s arm above the heart.
• D. Notify the healthcare provider and prepare for surgery.

Correct answer: B

Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.

2. A client with pneumonia is receiving intravenous (IV) antibiotics. Which assessment finding indicates that the client's condition is improving?

• A. Client's respiratory rate decreases from 24 to 20 breaths per minute
• B. White blood cell count decreases to normal range
• C. Client reports increased energy levels
• D. Cough becomes productive with green sputum

Correct answer: B

Rationale: A decrease in white blood cell count indicates that the infection is responding to treatment and the client's condition is improving. Monitoring the white blood cell count is a more objective indicator of the body's response to the antibiotics. Choices A, C, and D may also be positive signs, but they are less specific and may vary among individuals. Respiratory rate alone may not be sufficient to indicate improvement, as other factors can influence it. Energy levels and cough characteristics are subjective and may not always correlate with the effectiveness of antibiotic treatment.

3. Which of the following statements reflects appropriate teaching to prevent injury in a client with rheumatoid arthritis?

• A. Use heat applications to relieve swelling and stiffness.
• B. Take warm showers before activity.
• C. Use cold packs to relieve joint pain.
• D. Take prescribed anti-inflammatory medications with meals.

Correct answer: C

Rationale: The correct answer is C. Using cold packs to relieve joint pain is appropriate for clients with rheumatoid arthritis as cold therapy is more effective at reducing inflammation and pain in these conditions. Heat applications may exacerbate the symptoms by increasing swelling. Taking warm showers before activity may provide comfort but does not directly address joint pain or prevent injury. While anti-inflammatory medications are commonly prescribed, they are not directly related to preventing injury in clients with rheumatoid arthritis.

4. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

• A. Pale skin
• B. Increased heart rate
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

5. A client with hypertension has been prescribed a calcium channel blocker. What should the nurse include in the client's teaching plan?

• A. Monitor heart rate regularly
• B. Avoid potassium-rich foods
• C. Increase fluid intake to avoid dehydration
• D. Take the medication with food

Correct answer: A

Rationale: Corrected Rationale: Calcium channel blockers can cause bradycardia, so it is important for the client to monitor their heart rate regularly. This helps detect any significant changes in heart rate that may require medical attention. Choice B is incorrect because there is no need to avoid potassium-rich foods with calcium channel blockers. Choice C is incorrect as increasing fluid intake is not specifically related to calcium channel blockers. Choice D is incorrect as calcium channel blockers are usually taken with or without food, depending on the specific medication, but not specifically on an empty stomach.

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