Nursing Elites

1. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?

• A. Administer nitroglycerin sublingually.
• B. Obtain a 12-lead ECG.
• C. Measure the client's vital signs.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.

2. The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

• A. Place a pillow under the patient's lower legs.
• B. Turn the head toward one side with a large, soft pillow.
• C. Position legs flat against the bed.
• D. Raise the head of the bed to 45 degrees.

Correct answer: A

Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.

3. A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include?

• A. “Keep a nightlight on in the bathroom”
• B. “Set room temperature to 68 degrees Fahrenheit”
• C. “Place throw rugs over electrical cords”
• D. “Use chairs without armrests”

Correct answer: A

Rationale: The correct answer is A: 'Keep a nightlight on in the bathroom.' This safety measure is crucial for older adults to prevent falls by enhancing visibility during nighttime bathroom visits. Choice B is incorrect because setting the room temperature to 68 degrees Fahrenheit may not be universally suitable for all older adults, as individual preferences vary. Choice C is incorrect as placing throw rugs over electrical cords poses a tripping hazard rather than enhancing safety. Choice D is incorrect as using chairs without armrests may not provide adequate support and stability for older adults, increasing the risk of falls.

4. While providing care to a group of patients, which patient should the nurse prioritize seeing first?

• A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
• B. A bedridden patient with a reddened area on the buttocks who needs to be turned
• C. A patient on bed rest with renal calculi who needs to go to the bathroom
• D. A patient post-knee surgery who needs range of motion exercises

Correct answer: A

Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.

5. A client has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?

• A. Ankle-foot orthotic
• B. Continuous passive motion machine
• C. Abduction splint
• D. Sequential compression device

Correct answer: A

Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.

Similar Questions