Nursing Elites

1. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?

• A. Chest pain.
• B. Muscle spasms.
• C. Cool, moist skin.
• D. Incisional pain.

Correct answer: A

Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.

2. A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 91%
• B. Use of pursed-lip breathing
• C. Productive cough with green sputum
• D. Decreased breath sounds in the right lower lobe

Correct answer: D

Rationale: The correct finding the nurse should report to the provider is decreased breath sounds in the right lower lobe. This can indicate a respiratory infection or atelectasis in clients with COPD, requiring further evaluation and intervention. Choice A, an oxygen saturation of 91%, although slightly lower than normal, does not necessarily require immediate reporting unless the client's baseline is significantly higher. Choice B, the use of pursed-lip breathing, is actually a beneficial technique for clients with COPD to improve oxygenation and reduce shortness of breath, so it does not need reporting. Choice C, a productive cough with green sputum, can be common in clients with COPD and may indicate an infection, but it is not as concerning as decreased breath sounds in a specific lung lobe which may signify a more acute issue.

3. A nurse is caring for a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min, and the PR interval is 0.24 seconds. What cardiac rhythm should the nurse interpret this finding as?

• A. First-degree AV block.
• B. Premature ventricular contraction.
• C. Sinus bradycardia.
• D. Atrial fibrillation.

Correct answer: A

Rationale: The correct answer is A: First-degree AV block. A PR interval of 0.24 seconds indicates a prolonged PR interval, which is characteristic of first-degree AV block. This rhythm is considered benign and often does not require treatment. Choice B, premature ventricular contraction, is characterized by early, abnormal ventricular contractions and would not be indicated by the findings provided. Choice C, sinus bradycardia, would present with a normal PR interval but a heart rate less than 60 beats per minute. Choice D, atrial fibrillation, is characterized by an irregularly irregular rhythm with no identifiable P waves, which does not align with the findings of a prolonged PR interval in this scenario.

4. A client is receiving discharge teaching regarding a new prescription for amoxicillin. Which of the following client statements indicates an understanding of the teaching?

• A. I will take this medication until my symptoms are gone.
• B. I will take this medication until it is finished.
• C. I will take this medication on an empty stomach.
• D. I will take this medication with milk.

Correct answer: B

Rationale: The correct answer is B. It is crucial for clients to complete the entire course of antibiotics as prescribed, even if symptoms improve. This helps to ensure that the infection is fully treated and reduces the risk of developing antibiotic resistance. Choice A is incorrect because stopping the medication when symptoms disappear can lead to incomplete treatment. Choice C is incorrect as amoxicillin can be taken with or without food. Choice D is incorrect because taking amoxicillin with milk can decrease its absorption.

5. Which of the following actions is appropriate when administering a blood transfusion?

• A. Verify patient identity
• B. Administer medication
• C. Monitor vital signs
• D. Start blood transfusion without verification

Correct answer: A

Rationale: Verifying the patient's identity is a critical step when administering a blood transfusion to ensure that the correct blood product is given to the right patient. This process helps prevent errors and enhances patient safety. Choice B, 'Administer medication,' is incorrect because the focus during a blood transfusion should be on ensuring the correct blood product is administered. Choice C, 'Monitor vital signs,' is also important but comes after verifying the patient's identity. Choice D, 'Start blood transfusion without verification,' is incorrect and unsafe as patient identification verification is essential prior to starting any medical procedure, especially one as important as a blood transfusion.

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