Nursing Elites

1. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

• A. Axillary temperature 37.2°C (99°F)
• B. Apical pulse 100/min
• C. Respiratory rate 30/min
• D. Blood pressure 140/84 mm Hg

Correct answer: C

Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.

2. What are the dietary recommendations for a patient with pre-dialysis end-stage kidney disease?

• A. Reduce phosphorus intake to 700 mg/day
• B. Limit sodium intake to 1,500 mg/day
• C. Restrict protein intake to 0.55-0.60 g/kg/day
• D. Increase protein intake

Correct answer: A

Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. High phosphorus levels can be harmful to individuals with kidney disease as the kidneys may not be able to filter it effectively. While limiting sodium intake to 1,500 mg/day and restricting protein intake to 0.55-0.60 g/kg/day are important in managing kidney disease, the primary concern for this patient population is to control phosphorus levels. Increasing protein intake is not recommended as it can put additional strain on the kidneys. Therefore, option A is the most appropriate recommendation in this scenario.

3. A patient who experienced an acute episode of gastritis should avoid which type of foods?

• A. Avoid foods high in potassium
• B. Avoid foods high in sodium
• C. Increase exercise
• D. Drink milk as a snack

Correct answer: A

Rationale: Patients who have experienced an acute episode of gastritis should avoid foods high in potassium. Potassium-rich foods can irritate the gastric lining, exacerbating gastritis symptoms. Therefore, choices B, C, and D are incorrect. Avoiding foods high in sodium is beneficial for other health conditions like hypertension, increasing exercise is generally good for overall health but not specifically for gastritis management, and drinking milk may provide temporary relief for some but is not a definitive recommendation for gastritis management.

4. What are the early signs of hypokalemia on an ECG?

• A. Flattened T waves
• B. Elevated ST segments
• C. Prominent U waves
• D. Widened QRS complex

Correct answer: A

Rationale: Flattened T waves are an early sign of hypokalemia on an ECG. In hypokalemia, the T waves may flatten and eventually invert. Elevated ST segments are not typically associated with hypokalemia. Prominent U waves are seen in conditions like hypokalemia, but they are not considered an early sign. A widened QRS complex is more commonly associated with hyperkalemia rather than hypokalemia.

5. What are the expected findings in a patient with a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Severe headache and vomiting
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. In a thrombotic stroke, a blood clot forms in an artery supplying blood to the brain, leading to reduced blood flow to a specific area of the brain. This results in a gradual onset of neurological deficits, such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache and vomiting, and loss of sensation in the affected limb are more commonly associated with other types of strokes or medical conditions, not specifically thrombotic strokes. Thrombotic strokes typically present with gradual symptoms due to the gradual blockage of blood flow, leading to a progressive neurological deficit.

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