Nursing Elites

1. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?

• A. Administer nitroglycerin sublingually.
• B. Administer 2L of oxygen via nasal cannula.
• C. Administer aspirin 325 mg orally.
• D. Obtain a 12-lead ECG.

Correct answer: D

Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.

2. A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

• A. Holding the newborn in an en face position
• B. Asking the father to change the newborn's diaper
• C. Requesting the nurse to take the newborn to the nursery so she can rest
• D. Viewing the newborn's actions as uncooperative

Correct answer: D

Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.

3. Which lab test is used to assess renal function?

• A. Check blood glucose levels
• B. Monitor serum creatinine
• C. Monitor BUN
• D. Check electrolyte levels

Correct answer: B

Rationale: The correct answer is B: Monitor serum creatinine. Serum creatinine is a key indicator of renal function as it reflects the glomerular filtration rate. An increase in serum creatinine levels indicates impaired kidney function. Checking blood glucose levels (choice A) is not specific to assessing renal function but is used to diagnose diabetes. Monitoring BUN (choice C) is important but not as specific as serum creatinine in assessing renal function. Checking electrolyte levels (choice D) is essential in assessing kidney function but is not as specific as monitoring serum creatinine.

4. What is the best way to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Check for edema

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is the most accurate way to assess fluid balance in patients receiving diuretics. Monitoring daily weight allows healthcare providers to track changes in fluid status more precisely. While monitoring intake and output (choice B) is essential, it may not provide a comprehensive picture of overall fluid balance. Monitoring blood pressure (choice C) is important but may not directly reflect fluid balance. Checking for edema (choice D) is useful but may not be as sensitive as daily weight monitoring in assessing fluid balance.

5. A nurse is planning care for a client who has a history of falls. Which of the following actions should the nurse include in the plan of care?

• A. Keep all four side rails up.
• B. Ensure the client's bed is in the lowest position.
• C. Use nonskid footwear while ambulating.
• D. Place a bedside commode close to the client's bed.

Correct answer: C

Rationale: The correct answer is C: 'Use nonskid footwear while ambulating.' This action is crucial in preventing falls in clients with a history of falls as it provides better traction and stability while walking. Choice A, 'Keep all four side rails up,' is not recommended as it can lead to client restraint and is not a fall prevention strategy. Choice B, 'Ensure the client's bed is in the lowest position,' is important for preventing injuries from falls out of bed but does not directly address fall prevention during ambulation. Choice D, 'Place a bedside commode close to the client's bed,' is a good practice for toileting safety but does not specifically address preventing falls while walking.

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