Nursing Elites

1. A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse take next?

• A. Hold the medication.
• B. Call the healthcare provider.
• C. Administer the medication.
• D. Check the blood pressure.

Correct answer: C

Rationale: The correct action for the nurse to take next is to administer the medication. Atenolol is a beta-blocker commonly used post-myocardial infarction to reduce the workload of the heart. The client's apical pulse of 65 beats per minute is within the acceptable range after a myocardial infarction. Holding the medication or calling the healthcare provider is not necessary in this scenario as the pulse rate is appropriate for administering atenolol. Checking the blood pressure is not the priority in this situation, as the focus should be on the heart rate when administering atenolol.

2. The healthcare provider is assessing a client who has a nasogastric tube to low intermittent suction. Which finding indicates that the client may have developed hypokalemia?

• A. Muscle weakness and cramps.
• B. Nausea and vomiting.
• C. Constipation.
• D. Increased blood pressure.

Correct answer: A

Rationale: Muscle weakness and cramps are characteristic signs of hypokalemia, a condition marked by low levels of potassium in the blood. Potassium is essential for proper muscle function, and its deficiency can lead to muscle weakness and cramps. In the context of a client with a nasogastric tube to low intermittent suction, the loss of potassium through suctioning can contribute to the development of hypokalemia. Nausea and vomiting (choice B) are more commonly associated with gastrointestinal issues rather than hypokalemia. Constipation (choice C) is not a typical finding of hypokalemia; instead, it can be a sign of other gastrointestinal problems. Increased blood pressure (choice D) is not a direct manifestation of hypokalemia; in fact, low potassium levels are more commonly associated with decreased blood pressure.

3. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?

• A. I will increase my intake of vitamin C.
• B. I will avoid alcohol and tobacco.
• C. I will need to take folic acid supplements.
• D. I will avoid taking any medication without consulting my healthcare provider.

Correct answer: D

Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.

4. A client presents at a community-based clinic with complaints of shortness of breath, headache, often uses a gasoline-powered pressure washer to clean equipment and farm buildings. Which type of poisoning is the most likely etiology of this client's symptoms?

• A. asbestos
• B. silica dust
• C. histoplasmosis
• D. carbon monoxide

Correct answer: D

Rationale: The correct answer is D, carbon monoxide poisoning. This client's symptoms of shortness of breath and headache are consistent with carbon monoxide exposure, which can result from using gasoline-powered equipment in poorly ventilated areas. Asbestos (choice A) is linked to respiratory issues but does not typically present with these acute symptoms. Silica dust (choice B) exposure is associated with lung damage, not the symptoms described. Histoplasmosis (choice C) is a fungal infection and would not typically manifest with the symptoms presented by the client.

5. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

• A. Facial weakness and difficulty speaking.
• B. Decreased deep tendon reflexes in the legs.
• C. Inability to move the eyes.
• D. Respiratory distress and cyanosis.

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

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