Nursing Elites

1. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

• A. Heart rate
• B. Pedal pulses
• C. Lung sounds
• D. Pupil responses

Correct answer: D

Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.

2. The client is being taught about precautions with Coumadin therapy. Which over-the-counter medication should the client be instructed to avoid?

• A. Non-steroidal anti-inflammatory drugs
• B. Cough medicines with guaifenesin
• C. Histamine blockers
• D. Laxatives containing magnesium salts

Correct answer: A

Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). When a client is on Coumadin therapy, NSAIDs should be avoided because they can increase the risk of bleeding due to their antiplatelet effects. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not have a significant interaction with Coumadin therapy that would necessitate avoidance.

3. A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

• A. Reverse
• B. Airborne
• C. Standard precautions
• D. Contact

Correct answer: D

Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.

4. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

• A. Presence of blood in stools
• B. Oozing liquid stool
• C. Continuous rumbling flatulence
• D. Absence of bowel movements

Correct answer: B

Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.

5. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is crucial in this situation as coughing while consuming liquids can indicate a risk of aspiration. Assessing the gag reflex can help determine if the client is safe to swallow without inhaling fluids into the lungs, which could lead to further respiratory complications. Adding a thickening agent may not address the underlying issue of aspiration risk. Feeding the client only solid foods is not appropriate without assessing the swallowing safety first. Increasing the rate of intravenous fluids does not directly address the client's difficulty with liquid intake.

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