Nursing Elites

1. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

• A. Oral mucosa
• B. Conjunctivae
• C. Soles of the feet
• D. Ear lobes

Correct answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

2. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

3. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

• A. Notify the provider
• B. Check the condition of the client
• C. Document the occurrence in the electronic medical record
• D. Complete an incident report

Correct answer: B

Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.

4. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?

• A. Obtain a detailed medical history
• B. Administer nitroglycerin
• C. Conduct an ECG
• D. Administer morphine sulfate

Correct answer: B

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.

5. While obtaining the health and medication history of a client with a respiratory infection, the nurse learns that the client developed a rash the last time she took an antibiotic despite not being aware of any allergies. What information should the nurse provide to the client?

• A. Document the exact medication taken
• B. Ignore the symptom
• C. Stop taking antibiotics
• D. Continue with the current medication

Correct answer: A

Rationale: The correct answer is to instruct the client to document the exact medication taken. This is crucial for preventing future allergic reactions. By knowing the specific antibiotic that caused the rash, healthcare providers can avoid prescribing it again, reducing the risk of an allergic response. Choice B, 'Ignore the symptom,' is incorrect as ignoring a potential allergic reaction can lead to more severe complications. Choice C, 'Stop taking antibiotics,' is not advisable without proper guidance from a healthcare provider. Choice D, 'Continue with the current medication,' is also not recommended when there is a history of a rash related to antibiotic use.

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