Nursing Elites

1. A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?

• A. Request a prescription for an antihypertensive medication.
• B. Ask the client if they are having pain.
• C. Request a prescription for an antianxiety medication.
• D. Return in 30 minutes to recheck the client’s BP.

Correct answer: B

Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.

2. When assessing readiness to learn about insulin self-administration, what indicates the client is ready to learn?

• A. I can concentrate best in the morning.
• B. I feel anxious about learning the process.
• C. I have a lot of questions about insulin.
• D. I am not sure if I can manage this at home.

Correct answer: A

Rationale: The correct answer is A: 'I can concentrate best in the morning.' Readiness to learn is indicated by the client's ability to focus and concentrate, as mentioned in the question. Choice B, 'I feel anxious about learning the process,' indicates apprehension and may hinder the learning process. Choice C, 'I have a lot of questions about insulin,' shows interest but does not directly indicate readiness to learn. Choice D, 'I am not sure if I can manage this at home,' reflects uncertainty and lack of confidence, which may suggest the client is not fully prepared to learn.

3. A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include?

• A. Use tracheostomy covers when going outdoors.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Do not remove the outer cannula for routine cleaning.
• D. Clean around the stoma with normal saline.

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when going outdoors. This instruction is important as it helps protect the airway from dust and other particles, reducing the risk of infection or irritation. Choice B is incorrect because maintaining sterile technique is crucial during tracheostomy care to prevent infections, but it is not the most pertinent instruction in this scenario. Choice C is incorrect as removing the outer cannula is not a routine cleaning procedure and should only be done by healthcare professionals when necessary. Choice D is incorrect because cleaning around the stoma with normal saline is not recommended as it can cause irritation to the skin and stoma site.

4. A client with prostate cancer declines to discuss concerns after the provider discusses treatment options. What statement should the nurse make?

• A. I am available to talk if you should change your mind.
• B. It’s important to discuss your concerns with the provider.
• C. You need to make a decision about your treatment options.
• D. Your concerns will be addressed at a later time.

Correct answer: A

Rationale: Offering to talk later if the client changes their mind respects their current choice and keeps the dialogue open. Choice B is not the best response as it may pressure the client to share concerns. Choice C is incorrect as it imposes a decision on the client. Choice D does not acknowledge the client's feelings in the moment and postpones addressing concerns.

5. The healthcare professional is assessing a client with a history of rheumatoid arthritis. Which of the following assessment findings would be most concerning?

• A. Morning stiffness
• B. Joint deformities
• C. Fever
• D. Weight loss

Correct answer: C

Rationale: In a client with rheumatoid arthritis, the presence of fever is most concerning because it may indicate an infection or systemic involvement, necessitating immediate attention. Morning stiffness and joint deformities are common manifestations of rheumatoid arthritis itself and are expected findings in these clients. Weight loss can occur in rheumatoid arthritis due to various factors such as decreased appetite or systemic inflammation, but it is not as acutely concerning as fever, which may signal a more urgent issue.

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