Nursing Elites

1. A client with a history of hypertension is admitted with a blood pressure of 180/110 mm Hg. Which medication should the nurse prepare to administer?

• A. Atenolol (Tenormin)
• B. Nifedipine (Procardia)
• C. Hydrochlorothiazide (Microzide)
• D. Clonidine (Catapres)

Correct answer: D

Rationale: In this scenario of severe hypertension (180/110 mm Hg), the nurse should prepare to administer Clonidine (Catapres), which is an antihypertensive medication commonly used to rapidly lower blood pressure in acute situations. Atenolol and Nifedipine are also antihypertensive medications, but Clonidine is more appropriate for immediate blood pressure reduction in this critical situation. Hydrochlorothiazide is a diuretic often used for long-term management of hypertension, not for rapid lowering of severely elevated blood pressure.

2. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?

• A. Blood glucose of 250 mg/dL.
• B. Serum potassium of 3.5 mEq/L.
• C. Serum sodium of 135 mEq/L.
• D. Arterial blood pH of 7.30.

Correct answer: D

Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.

3. A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?

• A. To protect myself from your germs.
• B. To protect you because you can get an infection very easily.
• C. Until your white blood cell count increases.
• D. To keep others from getting your infection.

Correct answer: B

Rationale: Reverse isolation precautions protect the client from exposure to microorganisms from others.

4. During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?

• A. suggest that the client hires a cleaning service
• B. assist the client in organizing the living space
• C. assess the client's risk for falls
• D. provide the client with information on home safety

Correct answer: C

Rationale: The correct first action for the nurse to take is to assess the client's risk for falls. A cluttered living environment and poor lighting are significant risk factors for falls in the elderly. By assessing the client's risk for falls, the nurse can identify potential hazards and implement appropriate interventions to prevent falls. Suggesting hiring a cleaning service or assisting in organizing the living space may address the symptoms but not the root cause of the fall risk. Providing information on home safety is important but should come after assessing the specific risk factors for falls in this scenario.

5. The nurse is providing discharge teaching to a client with a new colostomy. Which statement by the client indicates a need for further teaching?

• A. I will avoid foods that cause gas.
• B. I will change my colostomy bag every week.
• C. I will use a skin barrier to protect the skin around the stoma.
• D. I will empty my colostomy bag when it is one-third full.

Correct answer: B

Rationale: The correct answer is B. Changing the colostomy bag every week is not sufficient; it should be changed more frequently to prevent leakage and skin irritation. Option A is correct as avoiding foods that cause gas can help manage colostomy-related symptoms. Option C is correct as using a skin barrier helps protect the skin around the stoma. Option D is correct as emptying the colostomy bag when it is one-third full helps prevent leakage and discomfort.

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