Nursing Elites

1. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

• A. Bilateral Wheezing
• B. Urticaria
• C. Peripheral edema
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Urticaria. An itchy rash following a change in detergent may indicate an allergic reaction, specifically urticaria (hives), which requires immediate attention. Urticaria can be a sign of a severe allergic reaction, such as anaphylaxis. Bilateral wheezing (choice A) may suggest respiratory issues like asthma but is not directly related to the skin rash. Peripheral edema (choice C) and elevated blood pressure (choice D) are not typically associated with an allergic reaction to laundry detergent and would not be the priority assessment findings in this scenario.

2. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?

• A. “Yes, I have. Do you have some questions about dying?”
• B. “Several times. Now, let’s get your dressing changed.”
• C. “A few times. It was peaceful and there was no pain.”
• D. “Yes, but you’re doing great. Are you concerned about dying?”

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.

3. The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. “I will use lemon juice and herbs for flavoring.”
• B. “I will not eat canned soups or frozen dinners.”
• C. “I can have salt substitutes to enhance the taste of my food.”
• D. “I will check the food labels for sodium content before buying.”

Correct answer: C

Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.

4. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

• A. Sluggish pupillary response to light
• B. Clear fluid leaking from the nose
• C. Complaint of severe headache
• D. Periorbital ecchymosis of the right eye

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

5. An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse?

• A. Reports a tearing, sharp pain between his shoulder blades
• B. Blood pressure reading of 200/100 mmHg 15 minutes later
• C. Rose-colored urine draining from the urinary catheter
• D. Sinus tachycardia with frequent premature ventricular beats (PVC)

Correct answer: A

Rationale: A tearing, sharp pain between the shoulder blades may indicate aortic dissection, a serious complication requiring immediate intervention. This symptom is highly concerning in a patient with a thoracic aneurysm. Choice B is not as urgent as the pain symptom described in choice A. Choice C could indicate hematuria but is not as critical as the potential aortic dissection in choice A. Choice D, sinus tachycardia with PVCs, may be related to the patient's condition but is not as indicative of an immediate life-threatening situation as the tearing, sharp pain indicative of aortic dissection.

Similar Questions