Nursing Elites

1. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

• A. Evaluate the client for sleep disturbances
• B. limit client exercise
• C. Report any client complaint of pain or discomfort
• D. Note and report the client's food and liquid intake during meals and snacks

Correct answer: D

Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.

2. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Pain scale rating of 9 on a 0-10 scale
• B. Last menstrual period was 7 weeks ago
• C. Reports white curdy vaginal discharge
• D. History of irritable bowel syndrome (IBS)

Correct answer: B

Rationale: The correct answer is B. A missed menstrual period could indicate a possible pregnancy-related issue, requiring urgent evaluation. Assessing the menstrual history in a female of reproductive age takes precedence in this scenario. Choice A, the pain scale rating, is important but not as urgent as evaluating the menstrual history. Choice C, reporting white curdy vaginal discharge, may suggest a vaginal infection but is not as critical as ruling out a potential pregnancy. Choice D, the history of irritable bowel syndrome, is relevant but not as crucial as determining pregnancy-related issues in this context.

3. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?

• A. Headache
• B. Pruritus
• C. Nausea
• D. Stridor

Correct answer: D

Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.

4. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbecue that afternoon. What question is most important for the triage nurse to ask this client?

• A. Have you recently traveled outside the United States?
• B. How high was your temperature when you returned home?
• C. Have you taken any medication to treat these symptoms?
• D. Is anyone else sick who was also at the picnic?

Correct answer: D

Rationale: The most important question for the triage nurse to ask the client in this scenario is whether anyone else who attended the picnic is also sick. This is crucial to identify a potential outbreak or common source of infection. Asking about recent travel may be important for infectious diseases but is not as relevant as identifying a common source among individuals who shared the same food. Inquiring about the client's temperature is important but does not provide immediate insight into the cause of symptoms. Asking about medication taken is relevant but not as critical as determining if others are affected, which could indicate a foodborne illness.

5. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad.' In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Feed the client a snack
• B. Empty the urinary drainage bag
• C. Offer the client oral fluids
• D. Stroke secondary to hemorrhage

Correct answer: D

Rationale: Elevated blood pressure, if left uncontrolled, significantly increases the risk of stroke secondary to hemorrhage and other cardiovascular events. This condition can lead to serious complications due to the increased pressure on the blood vessels in the brain. Choices A, B, and C are unrelated to the potential pathophysiological consequences of uncontrolled hypertension and are not the primary concern in this scenario.

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