Nursing Elites

1. A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?

• A. Evaluate the patency of the arteriovenous (AV) graft.
• B. Instruct the client to continue a fluid-restricted diet.
• C. Recommend support stockings for venous return.
• D. Monitor the client's serum albumin levels.

Correct answer: A

Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.

2. A client with a history of coronary artery disease is experiencing chest pain. What is the nurse's first action?

• A. Administer sublingual nitroglycerin
• B. Obtain a 12-lead electrocardiogram
• C. Call the healthcare provider
• D. Check the client's oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer sublingual nitroglycerin. Sublingual nitroglycerin is the first-line treatment for chest pain related to coronary artery disease. It helps dilate the coronary arteries and improve blood flow to the heart, providing immediate relief from ischemia. Administering nitroglycerin promptly can help alleviate the chest pain and prevent further complications. Obtaining a 12-lead electrocardiogram (Choice B) is important but should not delay the administration of nitroglycerin. Calling the healthcare provider (Choice C) can be done after initiating immediate treatment. Checking the client's oxygen saturation (Choice D) is relevant but not the first action to take in this scenario.

3. During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?

• A. Administer a bronchodilator as prescribed.
• B. Check the client's oxygen saturation.
• C. Reassure the client and encourage deep breathing.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.

4. A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?

• A. Prepare to administer warfarin.
• B. Assess the characteristics of the client's pain.
• C. Obtain recent partial thromboplastin time results.
• D. Monitor stool for the presence of blood.

Correct answer: D

Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.

5. The client is being taught to choose foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

• A. Three apricots
• B. Medium banana
• C. Naval orange
• D. Baked potato

Correct answer: D

Rationale: The correct answer is D: Baked potato. Baked potatoes are rich in potassium, which is essential in preventing digitalis toxicity by helping to maintain normal electrolyte levels. Apricots, bananas, and oranges are also sources of potassium, but a baked potato has a higher potassium content compared to the other options, making it a more effective choice for preventing digitalis toxicity.

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