Nursing Elites

1. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?

• A. I should apply clean dressings over blood-saturated dressings and hold pressure.
• B. I will rinse the wound with hot water to cleanse it.
• C. I can remove the dressing once the bleeding stops.
• D. I should apply antibiotic ointment directly to the wound.

Correct answer: A

Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.

2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

3. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsening with deep breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

4. A client has been prescribed albuterol. Which of the following is a priority adverse effect the nurse should monitor?

• A. Tachycardia
• B. Bradycardia
• C. Dizziness
• D. Hypertension

Correct answer: A

Rationale: Corrected Rationale: Albuterol, a beta-2 adrenergic agonist, can lead to tachycardia due to its stimulant effect on beta-2 receptors in the heart. Monitoring for tachycardia is crucial as it can be a sign of excessive sympathetic stimulation and may lead to severe complications. Bradycardia, dizziness, and hypertension are less likely adverse effects of albuterol, making them lower priority for monitoring in this context.

5. A nurse is caring for a client who has end-stage osteoporosis and is reporting severe pain. The client’s respiratory rate is 14 per minute. Which of the following medications should the nurse prioritize administering?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: Hydromorphone, an opioid, is the most appropriate option for managing severe pain in this context. Opioids provide fast-acting relief for acute pain associated with advanced osteoporosis. Promethazine (Choice A) is an antihistamine and not indicated for pain relief. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may increase the risk of bleeding and is not recommended for severe pain management. Amitriptyline (Choice D) is a tricyclic antidepressant that is not the first-line treatment for severe acute pain.

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