Nursing Elites

1. A client with a history of coronary artery disease is admitted with chest pain. Which assessment finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Respiratory rate of 20 breaths per minute.
• C. Blood pressure of 130/80 mm Hg.
• D. Chest pain radiating to the left arm.

Correct answer: D

Rationale: Chest pain radiating to the left arm is a classic symptom of a myocardial infarction (heart attack) in individuals with coronary artery disease. This finding indicates that the heart muscle may not be receiving adequate oxygen, which requires immediate intervention to prevent further damage or complications. The other assessment findings (heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 130/80 mm Hg) are within normal limits and do not suggest an acute, life-threatening condition like myocardial infarction.

2. A client with a history of peptic ulcer disease is admitted with sudden severe abdominal pain. Which finding indicates the possibility of a perforated ulcer?

• A. Bowel sounds are hyperactive in all quadrants.
• B. Abdomen is soft and nondistended.
• C. The client reports sudden severe abdominal pain.
• D. Blood pressure of 110/70 mm Hg.

Correct answer: C

Rationale: The correct answer is C. Sudden severe abdominal pain is a key clinical manifestation of a perforated ulcer. The sudden onset of severe pain is concerning for a perforation in the ulcer, which can lead to peritonitis if not promptly addressed. Choices A, B, and D are incorrect because hyperactive bowel sounds, a soft and nondistended abdomen, and a blood pressure of 110/70 mm Hg are not specific indicators of a perforated ulcer. Hyperactive bowel sounds may suggest increased gastrointestinal motility, a soft abdomen may not necessarily indicate a perforation, and a blood pressure of 110/70 mm Hg is within normal limits and does not directly relate to a perforated ulcer.

3. A client with a history of diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which finding requires immediate intervention?

• A. Blood glucose of 200 mg/dL.
• B. Serum bicarbonate of 20 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Urine output of 50 mL in 4 hours.

Correct answer: D

Rationale: In a client with diabetic ketoacidosis (DKA), urine output of 50 mL in 4 hours indicates oliguria, which is a concerning sign of decreased renal perfusion and potential renal failure. This finding requires immediate intervention to prevent further deterioration of kidney function.\n\nChoice A (Blood glucose of 200 mg/dL) is elevated but not the most urgent concern in this scenario. Choice B (Serum bicarbonate of 20 mEq/L) reflects metabolic acidosis, which is expected in DKA but does not require immediate intervention. Choice C (Blood pressure of 140/90 mm Hg) is slightly elevated but not acutely concerning in the context of DKA.

4. A government office worker is seen in the emergency room after opening an envelope containing a powder-like substance which is being tested for anthrax. Which discharge instruction should the nurse provide the client concerning inhalation anthrax?

• A. return to the emergency room if flu-like symptoms develop within 42 days
• B. notify co-workers to get the anthrax vaccine at the public health department
• C. isolation from friends and family members is recommended for 3 weeks
• D. cleanse all surfaces touched with pre-moistened antibacterial wipes

Correct answer: A

Rationale: The correct answer is to instruct the client to return to the emergency room if flu-like symptoms develop within 42 days. Flu-like symptoms can be an early sign of inhalation anthrax, and prompt medical intervention is crucial. Choice B is incorrect because the focus should be on the affected individual seeking medical attention rather than vaccinating others. Choice C is incorrect as isolation from friends and family members is not a standard recommendation for inhalation anthrax. Choice D is also incorrect as cleansing surfaces is important for infection control but may not be the priority when facing potential exposure to anthrax.

5. A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?

• A. Elevate the affected leg on a pillow.
• B. Apply a warm compress to the affected leg.
• C. Perform passive range-of-motion exercises on the affected leg.
• D. Encourage the client to ambulate frequently.

Correct answer: A

Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.

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