Nursing Elites

1. A client with a history of angina is scheduled for an exercise electrocardiography (ECG) test. The nurse should explain that the purpose of this test is to evaluate which factor?

• A. The heart's response to physical stress
• B. The client's overall physical fitness
• C. The presence of electrolyte imbalances
• D. The effectiveness of anti-anginal medications

Correct answer: A

Rationale: An exercise electrocardiography (ECG) test is used to evaluate the heart's response to physical stress. During the test, the heart's electrical activity is monitored while the client exercises, helping to identify any areas of ischemia or abnormal rhythms. This test helps healthcare providers assess the heart's function and detect any potential issues related to angina or other cardiac conditions. Choice B, the client's overall physical fitness, is incorrect because the test primarily focuses on the heart's response to stress rather than the client's general physical fitness. Choice C, the presence of electrolyte imbalances, is incorrect as this test is not specifically designed to evaluate electrolyte levels. Choice D, the effectiveness of anti-anginal medications, is incorrect as the main purpose of the test is to assess the heart's response to physical stress, not medication effectiveness.

2. The nurse is preparing to administer an intravenous dose of potassium chloride to a client with hypokalemia. The nurse should monitor for which potential complication?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hypernatremia
• D. Hypercalcemia

Correct answer: A

Rationale: When administering potassium chloride to a client with hypokalemia, the nurse should monitor for hyperkalemia. Potassium chloride supplementation aims to increase potassium levels in individuals with hypokalemia. However, excessive administration can lead to hyperkalemia, which can be a serious and potentially life-threatening complication. Monitoring potassium levels is crucial to prevent this adverse outcome. Hypokalemia (Choice B) is the condition being treated, so it is not a complication of treatment. Hypernatremia (Choice C) refers to high sodium levels and is not directly related to the administration of potassium chloride. Hypercalcemia (Choice D) is an elevated calcium level and is not a common complication associated with potassium chloride administration in hypokalemia.

3. The nurse is caring for a client diagnosed with deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care to prevent the complication of pulmonary embolism?

• A. Encourage ambulation as tolerated.
• B. Administer anticoagulants as prescribed.
• C. Apply cold compresses to the affected area.
• D. Encourage the use of incentive spirometry.

Correct answer: B

Rationale: Administering anticoagulants as prescribed is crucial in preventing the complication of pulmonary embolism in clients with deep vein thrombosis. Anticoagulants help prevent the formation of new clots and the enlargement of existing ones, thereby reducing the risk of a pulmonary embolism. Encouraging ambulation as tolerated is beneficial for preventing complications related to immobility, but it is not the primary intervention to prevent pulmonary embolism in this case. Applying cold compresses to the affected area may help with pain and swelling but does not address the prevention of pulmonary embolism. Encouraging the use of incentive spirometry is more relevant in preventing respiratory complications such as atelectasis, not specifically pulmonary embolism.

4. A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. What should the nurse check the client for next?

• A. Smoking history
• B. Recent exposure to allergens
• C. History of recent insect bites
• D. Familial tendency toward peripheral vascular disease

Correct answer: A

Rationale: In this case, the nurse should check the client's smoking history next. Smoking is a significant risk factor for peripheral vascular disease, leading to the development of thrombophlebitis and claudication. It is important to assess this risk factor as it can significantly impact the client's vascular health and the progression of their current symptoms. Choices B, C, and D are incorrect because they are not directly related to the symptoms described by the client. Recent exposure to allergens or insect bites would typically present with different symptoms, and familial tendency toward peripheral vascular disease is not the immediate concern in this case.

5. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

• A. Assist the client to get back into bed.
• B. Report the chest pain episode to the healthcare provider.
• C. Tell the client to stand still and take the client's blood pressure.
• D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

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