Nursing Elites

1. A client with renal calculi is admitted. What is the priority nursing intervention?

• A. Monitor urinary output every shift.
• B. Administer pain medication as ordered.
• C. Strain all urine for stones.
• D. Increase fluid intake to flush the urinary tract.

Correct answer: C

Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.

2. What are the main differences between a stroke caused by ischemia and one caused by hemorrhage?

• A. Blockage in a blood vessel supplying the brain
• B. Bleeding in the brain due to a ruptured aneurysm
• C. Administering thrombolytics if within the treatment window
• D. Avoiding anticoagulants and preparing for surgery

Correct answer: A

Rationale: The correct answer is A: "Blockage in a blood vessel supplying the brain." Ischemic stroke is caused by a blockage in a blood vessel supplying the brain, leading to reduced blood flow. Hemorrhagic stroke, on the other hand, is caused by bleeding in the brain due to a ruptured blood vessel. Choices B, C, and D are incorrect. Administering thrombolytics, avoiding anticoagulants, and preparing for surgery are specific management strategies that may apply to ischemic or hemorrhagic strokes but do not define the main differences between the two types of strokes.

3. A forensic nurse is using the epidemiological triangle to explain factors that contribute to violent behavior. Which of the following factors should the nurse identify as an environmental factor in the epidemiological triangle?

• A. Crowded living conditions
• B. Traumatic brain injury
• C. Alzheimer's disease
• D. Impaired coping abilities

Correct answer: A

Rationale: Crowded living conditions are considered an environmental factor in the epidemiological triangle as they can contribute to the spread of violence. In this context, environmental factors refer to external influences such as social and physical environments. Traumatic brain injury, Alzheimer's disease, and impaired coping abilities are not typically classified as environmental factors in the epidemiological triangle. Traumatic brain injury and Alzheimer's disease are more related to individual health conditions, while impaired coping abilities are more focused on individual psychological factors rather than external environmental influences.

4. A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client?

• A. Remain still once the gel pads are attached
• B. I will be placing electrodes on your chest
• C. I will lower the head of your bed so you can sit up
• D. Breathe normally throughout the procedure

Correct answer: A

Rationale: The correct answer is A. Instructing the client to remain still once the gel pads are attached is crucial to obtaining accurate ECG readings. Choice B is incorrect as electrodes are typically placed on the chest, not the breast. Choice C is incorrect because the client should lie flat during an ECG, not sit up. Choice D is incorrect because the client should breathe normally, rather than holding their breath, throughout the procedure.

5. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?

• A. Give detailed information about the medication, including its potential side effects.
• B. Refer the client to the healthcare provider for more information.
• C. Give a brief explanation and administer the medication.
• D. Ask another nurse to explain the medication and proceed.

Correct answer: B

Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.

Similar Questions