Nursing Elites

1. A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?

• A. Administer an antihypertensive medication as prescribed.
• B. Monitor the client's urine output.
• C. Administer oxygen therapy as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: D

Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.

2. An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?

• A. Explain that this is an expected occurrence with aging.
• B. Observe the lower extremities for signs of muscle atrophy.
• C. Review the medical record for recent diagnostic test results.
• D. Ask the client to describe the changes that have occurred.

Correct answer: D

Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.

3. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

• A. Perform an otoscopic examination
• B. Measure the child's abdominal girth
• C. Collect a urine specimen for routine urinalysis
• D. Obtain a blood specimen for serum electrolytes

Correct answer: C

Rationale: Collecting a urine specimen for routine urinalysis is the next appropriate intervention. The symptoms described, including facial edema and tea-colored urine, are indicative of glomerulonephritis, a condition affecting the kidneys. A urine specimen can help assess renal function and the presence of blood and protein in the urine, which are common in glomerulonephritis. Performing an otoscopic examination (Choice A) is not relevant to the presenting symptoms. Measuring the child's abdominal girth (Choice B) is not necessary at this point as it does not directly address the urinary symptoms. Obtaining a blood specimen for serum electrolytes (Choice D) may provide information about electrolyte imbalances but is not the most appropriate initial step in this case.

4. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Elevate the head of the bed.
• C. Assess the client's level of consciousness.
• D. Obtain a sputum culture.

Correct answer: A

Rationale: Administering oxygen therapy as prescribed is the initial priority when managing an exacerbation of COPD. In COPD exacerbations, the primary concern is hypoxemia due to impaired gas exchange. Administering oxygen helps to improve oxygenation and prevent further complications. Elevating the head of the bed can aid in breathing comfort but is not the priority over ensuring adequate oxygen supply. Assessing the client's level of consciousness is important but comes after ensuring oxygenation. Obtaining a sputum culture is relevant for identifying pathogens but is not the immediate priority in addressing hypoxemia.

5. A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Headache
• C. Elevated blood pressure
• D. Low urine output

Correct answer: C

Rationale: In a client with chronic kidney disease receiving erythropoietin therapy, elevated blood pressure is the most concerning assessment finding. Erythropoietin can increase red blood cell production, leading to thicker blood, which in turn can elevate blood pressure. Elevated blood pressure in this scenario may indicate worsening hypertension, which requires prompt intervention to prevent complications such as stroke, heart attack, or further kidney damage. Increased fatigue (choice A) is a common symptom in CKD patients and can be expected with erythropoietin therapy. Headache (choice B) can occur but is less concerning than elevated blood pressure in this context. Low urine output (choice D) is a significant finding in CKD, but in a client receiving erythropoietin, elevated blood pressure takes precedence due to its potential for immediate adverse effects.

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