Nursing Elites

1. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

• A. Troponin level of 0.5 ng/mL
• B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
• C. Serum potassium of 4.5 mEq/L
• D. Blood glucose of 180 mg/dL

Correct answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

2. A client with a tracheostomy collar has a decrease in heart rate and oxygen saturation during tracheal suctioning. Which of the following actions should the nurse take?

• A. Elevate the head of the bed.
• B. Remove the inner cannula.
• C. Irrigate the stoma.
• D. Discontinue suctioning.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to discontinue suctioning. Suctioning should be stopped immediately to prevent further decrease in heart rate and oxygen saturation. Elevating the head of the bed may help with oxygenation, but the priority is to stop the suctioning procedure. Removing the inner cannula or irrigating the stoma are not appropriate actions and could worsen the client's condition.

3. The healthcare provider is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD). Which assessment finding would be most concerning?

• A. Barrel chest
• B. Clubbing of the fingers
• C. Cough with sputum production
• D. Use of accessory muscles

Correct answer: D

Rationale: The use of accessory muscles is the most concerning finding in a client with COPD. It indicates increased work of breathing and may signal respiratory distress, requiring immediate attention. Barrel chest is a common physical characteristic in individuals with COPD due to chronic air trapping and hyperinflation of the lungs but is not as acutely concerning as the use of accessory muscles. Clubbing of the fingers is a late sign of chronic hypoxia and is often seen in conditions with prolonged hypoxemia but is not as acute as the use of accessory muscles. Cough with sputum production is a common symptom in COPD due to excess mucus production but does not indicate immediate respiratory distress as the use of accessory muscles does.

4. A client who is postoperative following abdominal surgery has an eviscerated wound. What should the nurse do first?

• A. Cover the incision with a moist sterile dressing.
• B. Notify the surgeon immediately.
• C. Assess the client's vital signs.
• D. Place the client in a supine position with knees bent.

Correct answer: A

Rationale: The initial action the nurse should take after discovering a client's eviscerated wound is to cover the incision with a moist sterile dressing. This step is crucial to protect the exposed tissue, prevent infection, and create a conducive environment for healing. While notifying the surgeon is important, addressing the wound immediately takes precedence. Assessing vital signs is essential but should follow the immediate intervention of covering the wound. Placing the client in a supine position with knees bent is not the priority in managing an eviscerated wound; the first step is to cover the wound to protect the exposed tissue.

5. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

• A. Remove the safety pin from the extinguisher.
• B. Aim the extinguisher at the base of the fire.
• C. Squeeze the handle to release the extinguishing agent.
• D. Sweep the extinguisher from side to side.

Correct answer: A

Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.

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