Nursing Elites

1. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

• A. Obtain the blood pressure under the same conditions each time
• B. Use a different arm for each measurement
• C. Measure the blood pressure while the client is standing
• D. Take multiple readings at different times of the day

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

2. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

• A. “I will determine the most important client problems that we should address.”
• B. “I will review the past medical history on the client’s record to gather more information.”
• C. “I will carry out the new prescriptions from the provider.”
• D. “I will ask the client if their nausea has resolved.”

Correct answer: A

Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.

3. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

• A. Liver damage
• B. Renal failure
• C. Gastric bleeding
• D. Heart attack

Correct answer: A

Rationale: Correct Answer: Large doses of acetaminophen can cause liver damage, which is a known adverse effect of the medication. Acetaminophen is metabolized in the liver, and excessive amounts can overwhelm the liver's ability to process it, leading to hepatotoxicity. Renal failure (Choice B) is not typically associated with acetaminophen use. Gastric bleeding (Choice C) is more commonly linked to nonsteroidal anti-inflammatory drugs (NSAIDs) rather than acetaminophen. Heart attack (Choice D) is not a recognized adverse effect of acetaminophen, which primarily affects the liver when taken in large amounts.

4. When initiating cardiopulmonary resuscitation (CPR), what assessment finding must the healthcare provider confirm before beginning chest compressions?

• A. Absence of a pulse
• B. Presence of a pulse
• C. Respiratory rate
• D. Blood pressure

Correct answer: A

Rationale: The correct answer is A: Absence of a pulse. Prior to initiating chest compressions during CPR, it is essential to confirm the absence of a pulse. Chest compressions are indicated when there is no detectable pulse as it signifies cardiac arrest. Checking for a pulse is a critical step to ensure that CPR is performed on individuals who truly require it. Choices B, C, and D are incorrect because focusing on the presence of a pulse, respiratory rate, or blood pressure before starting chest compressions can delay life-saving interventions in a person experiencing cardiac arrest.

5. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?

• A. A client who has a new diagnosis of adrenal insufficiency
• B. A client who has heart failure
• C. A client who is receiving treatment for diabetic ketoacidosis
• D. A client who has abdominal ascites

Correct answer: B

Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.

Similar Questions