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. An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor signs of increased bleeding
• B. Instruct on the use of incentive spirometry
• C. Observe for confusion and restlessness
• D. Administer intravenous opioids for severe pain

Correct answer: A

Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.

3. A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?

• A. Ask the client to complete a food diary for the last 3 days
• B. Review the client’s lab data to determine her TSH, T3, and T4 levels
• C. Interview the client about her use of laxatives and diuretics
• D. Encourage the client to describe her daily exercise regimen

Correct answer: C

Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.

4. Parents who have one male child with sickle cell anemia are concerned about having more children with the disease. What client teaching should the nurse provide?

• A. All future children will be carriers, but will not necessarily have the disease
• B. There is a chance that each future child will have the disease
• C. Only male children cannot inherit the sickle cell disease trait
• D. Only one out of four of their children will definitely manifest the disease

Correct answer: B

Rationale: The correct answer is B. Each child has a 25% chance of having sickle cell anemia if both parents are carriers of the trait. Choice A is incorrect because not all future children will be carriers; some may have the disease. Choice C is incorrect as both male and female children can inherit the sickle cell disease trait. Choice D is incorrect as the chance is not fixed at one out of four; each child has an independent 25% chance of having the disease.

5. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Vanilla frozen yogurt
• B. Vegetable juice
• C. Clear beef broth
• D. Canned fruit cocktail

Correct answer: A

Rationale: The correct answer should be provided as choice E: Vanilla frozen yogurt. For a postoperative full liquid diet, the nurse should encourage the client to eat foods that are fully liquid and easy to digest. Vanilla frozen yogurt is a suitable choice as it provides calories and nutrients while being in a liquid form. Creamy peanut butter, vegetable juice, and canned fruit cocktail are not appropriate for a full liquid diet as they are not fully liquid and may not be easy to digest. Creamy peanut butter is solid, vegetable juice is not fully liquid, and canned fruit cocktail contains solid pieces.

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