Nursing Elites

1. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?

• A. Apply a dressing to the ulcer.
• B. Reposition the patient every 2 hours.
• C. Provide the patient with pain medication.
• D. Clean the ulcer with normal saline.

Correct answer: B

Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.

2. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

• A. Determining the level of comfort
• B. Changing the patient's position
• C. Identifying immobility hazards
• D. Assessing circulation

Correct answer: B

Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient every 2 hours can be delegated to nursing assistive personnel as it involves physically moving the patient. Tasks like determining the level of comfort (choice A) and assessing circulation (choice D) are clinical judgments that require a nursing license and should be performed by the nurse. Similarly, identifying immobility hazards (choice C) involves critical thinking and assessment skills that are within the nurse's scope of practice.

3. 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.

4. A client with a new prescription for levothyroxine is receiving teaching from a nurse. Which statement indicates understanding of the teaching?

• A. I should take this with food
• B. I will see immediate results
• C. I might not realize the full effect of the medication for several weeks
• D. I should stop if I feel better

Correct answer: C

Rationale: The correct answer is C: 'I might not realize the full effect of the medication for several weeks.' Levothyroxine is a medication that may take several weeks for the full effect to be evident. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect because immediate results are not expected with levothyroxine. Choice D is incorrect because stopping the medication without consulting a healthcare provider can be harmful, even if the client feels better.

5. While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Temperature

Correct answer: C

Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.

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