Nursing Elites

1. 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.

2. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

• A. Verbalizes a fear of being in a confined space.
• B. Drank a glass of water in the past 2 hours.
• C. Reports left chest wall pain prior to admission.
• D. Experiences facial swelling after eating crab

Correct answer: C

Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.

3. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis, 'altered nutrition, less than body requirements related to anorexia, nausea, vomiting' is identified. Which intervention should the nurse include in this child's plan of care?

• A. Allow the child to eat foods desired and tolerated
• B. Restrict foods brought from fast food restaurants
• C. Recommend eating the same foods as siblings eat at home
• D. Encourage a variety of large portions of food at every meal

Correct answer: A

Rationale: Allowing the child to choose foods can help improve intake and reduce nausea. Choice A is the correct intervention as it empowers the child to select foods they desire and can tolerate, which is crucial in ensuring adequate nutrition intake. Choice B is incorrect because restricting certain foods can further limit the child's options and may not address the underlying issues. Choice C is incorrect as it doesn't consider the specific needs and preferences of the child with altered nutrition. Choice D is incorrect as encouraging large portions of food at every meal may be overwhelming for a child experiencing anorexia, nausea, and vomiting.

4. When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.

• A. Breast screening for older women
• B. Rehabilitation services for stroke victims
• C. Blood pressure assessments
• D. Antepartum nutritional counseling

Correct answer: A

Rationale: The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.

5. Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope?

• A. Pedal pulses
• B. Breath sounds
• C. Oxygen saturation
• D. Blood pressure

Correct answer: D

Rationale: The correct answer is 'D: Blood pressure.' It is crucial to check the client's blood pressure before ambulating them, especially if they have a history of syncope. Monitoring blood pressure helps to prevent falls by ensuring that the client's blood pressure is stable enough to tolerate the activity. Choices A, B, and C are not as critical in this scenario. Checking pedal pulses, breath sounds, or oxygen saturation is important but not as crucial as assessing blood pressure when preparing to ambulate a client with a history of syncope.

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