Nursing Elites

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

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

2. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?

• A. Place a pad under the client’s head
• B. Hold the client’s limbs tightly to prevent injury
• C. Lift the client into bed with the help of other staff members
• D. Insert a bite block into the client’s mouth

Correct answer: A

Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.

3. The nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?

• A. Use the complete name of the medication magnesium sulfate.
• B. Avoid abbreviating medication names to prevent errors.
• C. Use generic names only for medications.
• D. Document the dosage, route of administration, and complete medication name.

Correct answer: A

Rationale: The correct answer is A: 'Use the complete name of the medication magnesium sulfate.' When documenting medications, it is crucial to use the complete name to avoid confusion and errors. Abbreviating medication names (choice B) can lead to misinterpretation and errors in medication administration. Using generic names only for medications (choice C) may not provide enough specificity, leading to potential medication errors. While documenting the dosage and route of administration is important, it is also vital to include the complete medication name (choice D) for accurate record-keeping and to ensure clarity in medication administration.

4. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?

• A. Defer the bath until evening and pass on the information to the next shift.
• B. Tell the patient that daily morning baths are part of the 'normal' routine.
• C. Explain the importance of maintaining morning hygiene practices.
• D. Cancel hygiene for the day and attempt again in the morning.

Correct answer: A

Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.

5. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?

• A. Monitor the client's blood glucose level.
• B. Encourage the client to increase fluid intake.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: A

Rationale: The most important action for the LPN/LVN to take when a client with a history of diabetes mellitus experiences symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps assess the severity of hyperglycemia and guides further interventions. Encouraging the client to increase fluid intake (Choice B) may exacerbate the symptoms by further diluting the blood glucose concentration. Administering insulin as prescribed (Choice C) should be done based on the healthcare provider's orders and after assessing the blood glucose levels. Assessing the client's urine output (Choice D) is important but not the most immediate action needed in this scenario.

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