Nursing Elites

1. A client with coronary artery disease is prescribed a low-cholesterol diet. The nurse should reinforce which dietary selection made by the client?

• A. Eggs and bacon
• B. Oatmeal with fresh fruit
• C. Cream of chicken soup
• D. Grilled cheese sandwich

Correct answer: B

Rationale: Oatmeal with fresh fruit is a suitable choice for a client with coronary artery disease prescribed a low-cholesterol diet. This option is high in fiber and nutrients, making it a heart-healthy selection. Oatmeal and fresh fruits are low in cholesterol and saturated fats, which helps in managing coronary artery disease. Choices A, C, and D are higher in cholesterol and saturated fats, which can be detrimental for individuals with this condition.

2. Before administering a calcium channel blocker to a client with hypertension, what parameter should the nurse check?

• A. Serum calcium level
• B. Apical pulse
• C. Blood pressure
• D. Respiratory rate

Correct answer: C

Rationale: Before administering a calcium channel blocker to a client with hypertension, the nurse should check the client's blood pressure. Calcium channel blockers are prescribed to lower blood pressure, so it is essential to assess the current blood pressure to ensure safe administration and monitor the medication's effectiveness. Checking the serum calcium level (Choice A) is not necessary before administering a calcium channel blocker, as it does not directly impact the drug's action. Monitoring the apical pulse (Choice B) is important for other types of medications like beta-blockers, not specifically for calcium channel blockers. Assessing the respiratory rate (Choice D) is not directly related to administering calcium channel blockers for hypertension.

3. A client is receiving morphine for pain. Which of the following assessments is the priority?

• A. Urine output
• B. Pupil reaction
• C. Respiratory rate
• D. Bowel sounds

Correct answer: C

Rationale: The correct answer is C: Respiratory rate. Monitoring the respiratory rate is the priority assessment for a client receiving morphine due to the risk of respiratory depression. Morphine is a potent opioid that can cause respiratory depression, which is a serious adverse effect that can be life-threatening. Assessing the client's respiratory rate is crucial to detect any signs of respiratory depression early and intervene promptly. Assessing urine output is important but not as critical as monitoring for respiratory depression with morphine. Pupil reaction and bowel sounds are also important assessments but do not take precedence over monitoring the respiratory rate when a client is on morphine.

4. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

• A. Assist the client to get back into bed.
• B. Report the chest pain episode to the healthcare provider.
• C. Tell the client to stand still and take the client's blood pressure.
• D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

5. The healthcare provider is monitoring a client with left-sided heart failure. Which assessment finding indicates that the client's condition is worsening?

• A. Clear lung sounds
• B. Increased peripheral pulses
• C. Bibasilar crackles
• D. Improved activity tolerance

Correct answer: C

Rationale: Bibasilar crackles are abnormal lung sounds that indicate fluid accumulation in the lungs, a sign that left-sided heart failure is worsening. This finding suggests that the client's condition is deteriorating and requires prompt intervention to prevent further complications. Clear lung sounds (Choice A) are normal and would not indicate worsening heart failure. Increased peripheral pulses (Choice B) may be seen in conditions like anxiety or exercise, but not specifically in worsening left-sided heart failure. Improved activity tolerance (Choice D) would be a positive sign, not an indicator of worsening heart failure.

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