Nursing Elites

1. During a community health fair, the nurse conducts a blood pressure screening for a 60-year-old woman who has a blood pressure of 160/100 mm Hg. What should the nurse do first?

• A. Instruct the client to monitor her blood pressure at home
• B. Refer the client to her healthcare provider for further evaluation
• C. Educate the client on lifestyle changes to reduce blood pressure
• D. Recheck the blood pressure in 15 minutes

Correct answer: B

Rationale: When encountering a high blood pressure reading at a community health fair, it is essential for the nurse to refer the client to her healthcare provider for further evaluation. This step ensures that the client receives a comprehensive assessment, diagnosis, and appropriate management plan. In this scenario, it is crucial to prioritize professional evaluation over self-monitoring, lifestyle education, or immediate rechecking of the blood pressure. Referral to a healthcare provider allows for timely intervention and ongoing monitoring of the client's blood pressure to prevent potential complications.

2. A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?

• A. Elevate the affected leg on a pillow.
• B. Apply a warm compress to the affected leg.
• C. Perform passive range-of-motion exercises on the affected leg.
• D. Encourage the client to ambulate frequently.

Correct answer: A

Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.

3. During a home visit, the nurse observes that a client with limited mobility has difficulty accessing the bathroom. What should the nurse do first?

• A. suggest the client install a bedside commode
• B. assist the client in modifying the home environment
• C. refer the client to an occupational therapist
• D. educate the client on mobility aids

Correct answer: A

Rationale: The correct answer is to suggest that the client installs a bedside commode. This option provides an immediate solution to the client's difficulty accessing the bathroom. While modifying the home environment (Choice B) and referring the client to an occupational therapist (Choice C) are important steps, suggesting a bedside commode addresses the immediate need efficiently. Educating the client on mobility aids (Choice D) can be beneficial but may not be the most urgent action required in this scenario.

4. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?

• A. Jaundice.
• B. Ascites.
• C. Peripheral edema.
• D. Spider angiomas.

Correct answer: D

Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.

5. The client with congestive heart failure (CHF) is receiving discharge instructions. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself daily and report a weight gain of more than 2 pounds in 24 hours.
• B. I will take my diuretic medication in the morning.
• C. I will call my healthcare provider if I experience increased shortness of breath.
• D. I will drink at least 3 liters of fluid each day.

Correct answer: D

Rationale: The correct answer is D. Drinking at least 3 liters of fluid each day may be contraindicated for a client with CHF due to the risk of fluid overload. This can exacerbate heart failure symptoms and lead to complications. Options A, B, and C are all appropriate statements that demonstrate understanding of managing CHF and seeking appropriate medical attention when needed.

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