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. A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?

• A. Determine if the urinary bladder is distended
• B. Irrigate the indwelling urinary catheter
• C. Review the temperature graph for the last day
• D. Administer an antihypertensive agent

Correct answer: A

Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.

3. After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

• A. Dark amber urine draining via an indwelling catheter at a rate of 40 ml per hour
• B. Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 mg/dl or Eq/L (0.74 mmol/L SI)
• C. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62
• D. Respiratory rate of 10 breaths per minute

Correct answer: D

Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.

4. A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

• A. Distended, tortuous veins in the left hand
• B. The left radial pulse is 2+ bounding
• C. Auscultation of a thrill on the left forearm
• D. Assessment of a bruit on the left forearm

Correct answer: C

Rationale: Auscultation of a thrill on the left forearm is the correct observation indicating that the AV fistula is patent. A thrill is a palpable vibration or buzzing sensation felt over the fistula, indicating the presence of blood flow. Choices A, B, and D do not directly assess the patency of the fistula. Distended, tortuous veins in the left hand may indicate venous hypertension; a bounding radial pulse could suggest increased blood flow through an artery, but it does not confirm fistula patency; assessment of a bruit indicates turbulent blood flow, but it does not confirm patency.

5. While changing a client’s chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

• A. Apply a pressure dressing around the chest tube insertion site
• B. Assess the client for allergies to topical cleaning agents
• C. Measure the area of swelling and crackling
• D. Administer an oral antihistamine per PRN protocol

Correct answer: A

Rationale: A crackling sensation indicates subcutaneous emphysema, caused by air trapped under the skin. Applying a pressure dressing around the chest tube insertion site can help manage the issue by preventing further air leakage into the tissues. Choice B is incorrect because the crackling sensation is not related to allergies. Choice C is incorrect as measuring the area does not address the underlying cause. Choice D is incorrect as administering an oral antihistamine is not indicated for subcutaneous emphysema.

Similar Questions