Nursing Elites

1. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

2. A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?

• A. Osmolarity
• B. Glucose
• C. Albumin
• D. Platelets

Correct answer: B

Rationale: The correct answer is B: Glucose. Hydrocortisone can lead to increased blood glucose levels, so monitoring glucose is crucial to assess for hyperglycemia, a common side effect of corticosteroid therapy. Monitoring osmolarity (choice A) is not typically indicated in this scenario. Albumin (choice C) and platelets (choice D) are not directly affected by hydrocortisone therapy and are not the primary focus of monitoring in this case.

3. The client with chronic venous insufficiency is being taught about self-care measures. Which instruction should be included?

• A. Avoid wearing compression stockings
• B. Elevate legs above heart level when resting
• C. Apply heat packs to improve circulation
• D. Limit walking to prevent leg pain

Correct answer: B

Rationale: The correct instruction for a client with chronic venous insufficiency is to elevate their legs above heart level when resting. This position helps reduce venous pressure and edema, improving circulation. Avoiding compression stockings (choice A) is incorrect as they are beneficial in managing chronic venous insufficiency. Applying heat packs (choice C) is not recommended as heat can worsen edema. Limiting walking (choice D) is not advisable as regular, gentle exercise like walking can actually help improve circulation in patients with chronic venous insufficiency.

4. A client with a history of seizures is prescribed phenytoin. Which instruction should the nurse include in the discharge teaching?

• A. Report any signs of a sore throat or fever immediately
• B. Take the medication with antacids to reduce stomach upset
• C. Discontinue the medication if you feel drowsy
• D. Increase the dosage if you experience an aura

Correct answer: A

Rationale: The correct answer is A: 'Report any signs of a sore throat or fever immediately.' Phenytoin can cause blood dyscrasias, which can manifest as a sore throat or fever. These symptoms could indicate a serious side effect that requires immediate medical attention. Choice B is incorrect because phenytoin should not be taken with antacids as they can decrease its absorption. Choice C is incorrect because discontinuing phenytoin abruptly can lead to rebound seizures; drowsiness is a common side effect that may improve with time. Choice D is incorrect because adjusting the dosage of phenytoin should only be done under healthcare provider supervision, not based on experiencing an aura.

5. During the admission interview, an older client answers some questions inappropriately. The nurse notes that a hearing aid is in one ear. Which intervention is most helpful in assisting the client to hear the nurse’s question?

• A. Move to the client's other side.
• B. Speak louder into the client's ear with the hearing aid.
• C. Ask the client to adjust the hearing aid volume.
• D. Restate questions articulating consonants carefully.

Correct answer: D

Rationale: Restating questions with clear articulation is the most helpful intervention in assisting the client to hear the nurse's question. This approach ensures that the client can better understand the question, especially if there are issues with the hearing aid. Moving to the client's other side or speaking louder into the ear with the hearing aid may not effectively address the problem of clarity in communication. Asking the client to adjust the hearing aid volume assumes that the issue lies solely with the volume, while restating questions with clear articulation can help overcome various hearing difficulties.

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