Nursing Elites

1. A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?

• A. Heart rate and blood pressure
• B. Blood glucose levels
• C. Respiratory rate
• D. Liver function tests

Correct answer: A

Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.

2. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

3. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

• A. Plain yogurt sweetened with raw honey
• B. Peanuts in the shell, roasted or unroasted
• C. Aged farmer’s cheese with celery sticks
• D. Baked apples topped with dried raisins

Correct answer: A

Rationale: The correct answer is A: Plain yogurt sweetened with raw honey. This option is the best choice for a client with severe neutropenia undergoing chemotherapy because it is less likely to harbor harmful bacteria, which could cause infections due to the weakened immune system. Peanuts in the shell (choice B) may carry a risk of contamination, while aged farmer's cheese with celery sticks (choice C) and baked apples topped with dried raisins (choice D) may not be as safe as plain yogurt for a client with severe neutropenia.

4. The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?

• A. Assess for signs of lymphedema
• B. Encourage the client to perform arm exercises
• C. Provide pain relief through medication
• D. Recommend wearing a compression sleeve

Correct answer: A

Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.

5. A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin?

• A. Fetal heart tones located in the upper right quadrant
• B. Biophysical profile results showing oligohydramnios
• C. Regular contractions occurring every 10 minutes
• D. Sterile vaginal exam revealing 3 cm dilation

Correct answer: B

Rationale: Oligohydramnios (low amniotic fluid) is a significant concern before starting oxytocin and should be reported to ensure safe labor induction. This finding can indicate potential fetal compromise and requires immediate evaluation. Fetal heart tones located in a specific quadrant, regular contractions, and cervical dilation are common assessments during labor but are not as critical as oligohydramnios in this scenario.

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