Nursing Elites

1. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?

• A. A migraine headache
• B. An infection from the puncture site
• C. Low blood sugar
• D. Spinal fluid leakage (post-lumbar puncture headache)

Correct answer: D

Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.

2. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?

• A. Increase physical activity
• B. Decrease alcohol consumption
• C. Reduce intake of dairy products
• D. Avoid caffeine and spicy foods

Correct answer: A

Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.

3. The healthcare provider prescribes an IV infusion of isoproterenol in D5W at 300 mcg/hour. How many ml/hour should the nurse set the pump to?

• A. 100 ml/hour
• B. 75 ml/hour
• C. 60 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct infusion rate, convert 300 mcg/hour to mg/hour (300 mcg = 0.3 mg). Since the IV solution is 1 mg in 250 ml, the rate is calculated as 0.3 mg/hour = 75 ml/hour. Therefore, the nurse should set the pump to 75 ml/hour. Choice A (100 ml/hour) is incorrect as it does not reflect the accurate calculation. Choice C (60 ml/hour) is incorrect as it is lower than the correct rate. Choice D (125 ml/hour) is incorrect as it is higher than the correct rate.

4. A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?

• A. Bright red blood in the vomit.
• B. Elevated blood pressure and heart rate.
• C. Coffee ground emesis.
• D. Dark, tarry stools.

Correct answer: D

Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.

5. During an assessment of a client with congestive heart failure, the nurse is most likely to hear which of the following upon auscultation of the heart?

• A. S3 ventricular gallop
• B. Apical click
• C. Systolic murmur
• D. Split S2

Correct answer: A

Rationale: Correct Answer: An S3 ventricular gallop is an abnormal heart sound commonly heard in clients with congestive heart failure. This sound is indicative of fluid overload or volume expansion in the ventricles, which is often present in heart failure. <br> Incorrect Answers: <br> B: An apical click is not typically associated with congestive heart failure. <br> C: A systolic murmur may be heard in various cardiac conditions but is not specific to congestive heart failure. <br> D: A split S2 refers to a normal heart sound caused by the closure of the aortic and pulmonic valves at slightly different times during inspiration, not directly related to congestive heart failure.

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