Nursing Elites

1. When the client finds antiembolism stockings uncomfortably tight, what is the nurse's best action?

• A. Remove the stockings for an hour to relieve the pressure
• B. Pull the stockings down so that they are not constricting
• C. Measure the client's calf to ensure that they are the correct size
• D. Teach the client the purpose of wearing the stockings

Correct answer: D

Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.

2. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?

• A. Pupil response
• B. Motor function
• C. Respiratory status
• D. Short-term memory

Correct answer: C

Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.

3. A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI?

• A. Burning on urination
• B. Cloudy, dark urine
• C. Fever and chills
• D. Hematuria

Correct answer: C

Rationale: Fever and chills are systemic symptoms that may indicate a more severe infection or a complication of a urinary tract infection (UTI). While burning on urination and cloudy, dark urine are common symptoms of UTI, fever and chills suggest a more serious condition requiring immediate attention. Hematuria, which is blood in the urine, is also a concerning symptom but is more indicative of inflammation or infection rather than a complication.

4. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?

• A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
• B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
• C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
• D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?

Correct answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

5. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?

• A. Call the healthcare provider and report the finding.
• B. Reassess the client’s blood pressure at the next follow-up appointment.
• C. Administer an additional antihypertensive medication to the client.
• D. Teach the client lifestyle modifications to decrease blood pressure.

Correct answer: D

Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.

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