Nursing Elites

1. A client presents to the emergency department with complaints of chest pain and shortness of breath. The client's ECG shows ST-segment elevation. What is the priority nursing intervention?

• A. Administer aspirin as prescribed.
• B. Prepare the client for emergent coronary angiography.
• C. Administer oxygen therapy.
• D. Initiate CPR.

Correct answer: B

Rationale: In a client presenting with chest pain, shortness of breath, and ST-segment elevation on ECG, the priority nursing intervention is to prepare the client for emergent coronary angiography. This procedure is crucial in diagnosing and treating acute myocardial infarction promptly. Administering aspirin (Choice A) is important but not the priority over emergent coronary angiography. Administering oxygen therapy (Choice C) is supportive but does not address the underlying cause of the ST-segment elevation. Initiating CPR (Choice D) is not the priority in this scenario as the client is stable and conscious.

2. Which of the following is not an autoimmune disease?

• A. Multiple sclerosis
• B. Pernicious anemia
• C. Goodpasture syndrome
• D. Transfusion reaction

Correct answer: D

Rationale: The correct answer is D, Transfusion reaction. Transfusion reaction is not an autoimmune disease because it occurs when the immune system responds to foreign blood cells, not to the body's own cells. Choices A, B, and C (Multiple sclerosis, Pernicious anemia, Goodpasture syndrome) are autoimmune diseases where the immune system mistakenly attacks the body's own tissues or organs.

3. When starting on oral contraceptives, what should the nurse include in the education regarding the timing of the medication?

• A. Oral contraceptives should be taken at the same time each day to maintain stable hormone levels and prevent pregnancy.
• B. Oral contraceptives can be taken at any time of day, as long as the schedule is consistent.
• C. Oral contraceptives should be taken in the morning to avoid nighttime side effects.
• D. Oral contraceptives are effective immediately upon starting, regardless of timing.

Correct answer: A

Rationale: When educating a patient starting on oral contraceptives, it is essential to stress the importance of taking the medication at the same time each day. This ensures stable hormone levels, improving the effectiveness of the contraceptives in preventing pregnancy. Choice B is incorrect because consistency in timing is crucial for maintaining hormone levels. Choice C is incorrect as there is no specific requirement to take oral contraceptives in the morning to avoid side effects. Choice D is incorrect as oral contraceptives may take some time to become fully effective, and consistent timing is important for their efficacy.

4. A client with a pneumothorax is receiving oxygen therapy. Which assessment finding would indicate that the treatment is effective?

• A. Increased respiratory rate
• B. Decreased oxygen saturation levels
• C. Improved breath sounds on the affected side
• D. Increased dyspnea and chest pain

Correct answer: C

Rationale: In a client with a pneumothorax receiving oxygen therapy, improved breath sounds on the affected side would indicate effective treatment. This finding suggests that the collapsed lung is re-expanding, allowing air to flow more freely in and out of the affected area. Choices A, B, and D are incorrect: Increased respiratory rate, decreased oxygen saturation levels, and increased dyspnea and chest pain are signs of ineffective treatment or worsening of the condition in a client with a pneumothorax.

5. When starting on oral contraceptives, what important information should the nurse provide regarding the timing of the medication?

• A. Oral contraceptives must be taken at the same time each day to maintain consistent hormone levels and ensure effectiveness in preventing pregnancy.
• B. Oral contraceptives can be taken at any time of day as long as the schedule is consistent.
• C. Oral contraceptives should be taken with food to enhance absorption.
• D. Oral contraceptives can be skipped occasionally without significant consequences.

Correct answer: A

Rationale: When starting on oral contraceptives, it is crucial to take them at the same time each day to maintain consistent hormone levels and ensure effectiveness in preventing pregnancy. Choice B is incorrect because consistency in timing is essential for optimal efficacy. Choice C is inaccurate as oral contraceptives do not need to be taken with food for absorption. Choice D is incorrect because missing doses or skipping oral contraceptives can reduce their effectiveness in preventing pregnancy.

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