Nursing Elites

1. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

• A. CT scan
• B. MRI
• C. X-ray
• D. Ultrasound

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

2. A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?

• A. Decreases mucus production
• B. Reduces nasal congestion
• C. Increases cough production
• D. Reduces fever

Correct answer: C

Rationale: The correct answer is C: 'Increases cough production.' Guaifenesin is an expectorant that works by increasing cough production to help clear secretions from the airways. Option A is incorrect because guaifenesin does not decrease mucus production but rather helps to make the mucus easier to cough up. Option B is incorrect as guaifenesin does not reduce nasal congestion. Option D is incorrect because guaifenesin does not have any effect on reducing fever.

3. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?

• A. Monitor the patient's electrolyte levels.
• B. Assess the patient's blood pressure regularly.
• C. Monitor the patient's heart rate every 4 hours.
• D. Check the patient's urine output hourly.

Correct answer: B

Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.

4. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?

• A. Report any urine output greater than 30 mL/hr.
• B. Bruising on the arms and legs.
• C. Positive Trousseau's sign.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.

5. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?

• A. Change the catheter every 72 hours.
• B. Ensure the tubing is unkinked.
• C. Empty the drainage bag every 4 hours.
• D. Hang the drainage bag below the bladder.

Correct answer: D

Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.

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