Nursing Elites

1. An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a CT scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement?

• A. Administer an anti-inflammatory medication instead
• B. Explain the reason for using only non-narcotics
• C. Consult the healthcare provider about a stronger medication
• D. Administer a stronger medication as requested

Correct answer: B

Rationale: In this scenario, the nurse should explain the reason for using only non-narcotics. Following head trauma, non-narcotic medications such as acetaminophen are preferred to avoid masking symptoms of neurological changes, such as increased intracranial pressure, that could worsen after stronger pain medication. Administering an anti-inflammatory medication (Choice A) may not be appropriate as it may not address the severity of the headache. Consulting the healthcare provider about a stronger medication (Choice C) is important, but the immediate need is to educate the client on the rationale for using non-narcotic medications first. Administering a stronger medication as requested (Choice D) could potentially mask important symptoms and should be avoided in this situation.

2. A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?

• A. Evaluate the patency of the arteriovenous (AV) graft.
• B. Instruct the client to continue a fluid-restricted diet.
• C. Recommend support stockings for venous return.
• D. Monitor the client's serum albumin levels.

Correct answer: A

Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.

3. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

• A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
• B. Listen with the bell of the stethoscope at the same location
• C. Listen at a different location over the aortic area
• D. Switch to the apical area and reassess for S3 sounds

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

4. The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?

• A. Bananas
• B. Processed meats
• C. Low-fat yogurt
• D. Whole grains

Correct answer: B

Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.

5. A client with Addison's disease becomes confused and weak. What is the nurse's first action?

• A. Administer a dose of hydrocortisone immediately.
• B. Check the client’s electrolyte levels.
• C. Administer a dose of normal saline.
• D. Measure the client’s blood pressure in both arms.

Correct answer: A

Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.

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