Nursing Elites

1. 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.

2. An older client with SIRS has a temperature of 101.8°F, a heart rate of 110 beats per minute, and a respiratory rate of 24 breaths per minute. Which additional finding is most important to report to the healthcare provider?

• A. Serum creatinine of 2.0 mg/dL
• B. Elevated WBC count
• C. Blood pressure of 100/60 mmHg
• D. Oxygen saturation of 95%

Correct answer: A

Rationale: A serum creatinine level of 2.0 mg/dL indicates possible acute kidney injury, which can occur during severe systemic inflammatory response syndrome (SIRS). Reporting this value promptly allows for interventions to prevent further renal damage. Elevated WBC count (choice B) is a common feature of SIRS and may not be as urgently indicative of immediate organ damage as high creatinine levels. A blood pressure of 100/60 mmHg (choice C) is relatively low but may be a typical finding in SIRS; however, renal function is critical in this context. Oxygen saturation of 95% (choice D) is within normal limits and is not as concerning as a high creatinine level in this scenario.

3. A client with hypoglycemia is unresponsive. What is the nurse's priority action?

• A. Administer intravenous dextrose.
• B. Check the client's blood glucose level.
• C. Administer glucagon intramuscularly.
• D. Prepare to administer oral glucose.

Correct answer: C

Rationale: The correct answer is to administer glucagon intramuscularly. In an unresponsive hypoglycemic client, administering glucagon intramuscularly is the priority action as it helps raise blood glucose levels quickly. Intravenous dextrose may be challenging to administer in an unresponsive client. Checking the client's blood glucose level is important but not the priority when the client is unresponsive. Preparing to administer oral glucose is not ideal for an unresponsive client as they may not be able to swallow.

4. A client is being prepared for surgery and has been placed on NPO status. Which of the following is the nurse's priority assessment?

• A. Assess the client's understanding of the procedure
• B. Monitor the client's compliance with NPO status
• C. Check the client's vital signs
• D. Ensure the client's consent form is signed

Correct answer: B

Rationale: The correct answer is B. Monitoring the client's compliance with NPO status is the priority assessment. Ensuring the client remains NPO (nothing by mouth) is crucial to reduce the risk of aspiration during surgery. Assessing the client's understanding of the procedure is important but not the priority at this moment. Checking vital signs is also essential but ensuring NPO status takes precedence for patient safety. Ensuring the client's consent form is signed is necessary but not the priority assessment compared to maintaining NPO status.

5. A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?

• A. Take the medication with meals to prevent gastrointestinal upset.
• B. Report any symptoms of nausea, vomiting, or diarrhea.
• C. Monitor lithium levels regularly and maintain hydration.
• D. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) while on lithium.

Correct answer: D

Rationale: The correct answer is D. Clients taking lithium should avoid NSAIDs as they can increase lithium levels leading to toxicity. It is essential to monitor lithium levels regularly and maintain hydration to prevent toxicity. Reporting symptoms like nausea, vomiting, or diarrhea is important, but the key teaching point regarding lithium toxicity is to avoid NSAIDs.

Similar Questions