Nursing Elites

1. What are the key components of a neurological assessment?

• A. Assess level of consciousness and motor function
• B. Check for headache and nausea
• C. Monitor reflexes and pupil size
• D. Assess for tremors and confusion

Correct answer: A

Rationale: The correct answer is A. A neurological assessment includes evaluating the level of consciousness and motor function as they are key components in assessing neurological function. Choices B, C, and D are incorrect as headache, nausea, reflexes, pupil size, tremors, and confusion may be part of a neurological assessment but are not the key components that are fundamental for a comprehensive assessment.

2. A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?

• A. Turn the client onto their left side
• B. Irrigate the NG tube with sterile water
• C. Increase the suction pressure to relieve the blockage
• D. Remove the NG tube and replace it with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.

3. What are the nursing interventions for a patient with hypertension?

• A. Monitor blood pressure and educate the patient about lifestyle changes
• B. Administer antihypertensive medications and provide dietary education
• C. Provide regular monitoring of blood pressure and administer diuretics
• D. Provide regular blood glucose monitoring

Correct answer: A

Rationale: The correct nursing interventions for a patient with hypertension involve monitoring blood pressure and educating the patient about lifestyle changes. These interventions help in managing hypertension by keeping track of the patient's blood pressure readings and empowering them with knowledge to make lifestyle modifications such as adopting a healthy diet, regular exercise, stress management, and avoiding smoking and excessive alcohol consumption. Administering antihypertensive medications (choice B) is typically done by a healthcare provider rather than a nurse. While regular monitoring of blood pressure (choice C) is important, administering diuretics is a specific medical intervention that should be prescribed by a healthcare provider. Monitoring blood glucose (choice D) is more relevant for patients with diabetes rather than hypertension.

4. A nurse is caring for a client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

• A. Cross the client's legs at the knees
• B. Maintain the client's legs in a neutral position
• C. Avoid placing a pillow under the client's knees
• D. Elevate the client's legs

Correct answer: C

Rationale: The correct action to prevent dislocation of the prosthesis after hip replacement surgery is to avoid placing a pillow under the client's knees. Placing a pillow can cause hip adduction, leading to dislocation. Crossing the client's legs at the knees and elevating the client's legs can also increase the risk of hip dislocation. Maintaining the client's legs in a neutral position is important to prevent complications.

5. What should a person recommend to a client experiencing constipation?

• A. Increase fluid intake to prevent further dehydration
• B. Increase dietary fiber to promote regular bowel movements
• C. Administer a laxative to relieve constipation
• D. Encourage bed rest to allow for bowel function to return

Correct answer: B

Rationale: Increasing dietary fiber is an effective recommendation for clients experiencing constipation as it helps promote regular bowel movements. Choice A, increasing fluid intake, is also important but the most appropriate initial recommendation for constipation is to increase dietary fiber. Choice C, administering a laxative, should not be the first-line recommendation and is typically considered after dietary and lifestyle interventions. Choice D, encouraging bed rest, does not directly address constipation relief or prevention.

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