Nursing Elites

1. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?

• A. It decreases the viscosity of blood
• B. It leads to increased fluid retention
• C. It causes vasoconstriction of the blood vessels
• D. It enhances the excretion of potassium

Correct answer: C

Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.

2. During a tonic-clonic seizure, what is the nurse's priority intervention?

• A. Insert an oral airway
• B. Administer oxygen via nasal cannula
• C. Restrain the client's arms and legs
• D. Protect the client's head from injury

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.

3. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

• A. Compartment syndrome
• B. Deep vein thrombosis
• C. Wound infection
• D. All of the above

Correct answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

4. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?

• A. The client should bottle feed and pump her breast for 3 days following immunization
• B. The vaccine is given to produce maternal antibodies before lactation occurs
• C. The infant will receive immunization through the mother's breast milk
• D. The client should not get pregnant for 3 months after immunization

Correct answer: D

Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.

5. While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?

• A. Determine if the drainage has an unpleasant odor.
• B. Monitor the client's white blood cell count (WBC).
• C. Request a culture and sensitivity of the wound.
• D. Cleanse the wound with a sterile saline solution.

Correct answer: C

Rationale: Requesting a culture and sensitivity of the wound is the most crucial action in this scenario. This will help identify the specific organism causing the infection and determine its sensitivity to antibiotics, guiding appropriate antibiotic therapy. Option A is less critical as odor alone may not provide enough information about the type of infection. Monitoring the client's white blood cell count (WBC) in option B is important but not as immediate as obtaining a wound culture. Cleansing the wound with a sterile saline solution in option D is necessary but should follow after obtaining the culture results to ensure proper treatment.

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