Nursing Elites

1. A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Administer nitroglycerin sublingually.
• C. Obtain a 12-lead ECG.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.

2. A nurse is assessing a client who has a peripherally inserted central catheter (PICC). Which of the following findings should the nurse report to the provider?

• A. Redness at the insertion site.
• B. Swelling of the arm above the insertion site.
• C. A bruised area around the insertion site.
• D. A temperature of 37.2°C (99°F).

Correct answer: B

Rationale: Swelling of the arm above the insertion site is concerning as it can indicate complications like thrombosis, which require immediate attention. Redness at the insertion site is common and expected in the initial stages. A bruised area around the insertion site may result from the insertion procedure and is usually not alarming unless it worsens or becomes larger. A temperature of 37.2°C (99°F) is within the normal range and is not directly related to PICC complications.

3. A nurse is caring for a client who has acute pancreatitis. Which of the following laboratory findings should the nurse expect to be elevated?

• A. Hemoglobin
• B. Bilirubin
• C. Amylase
• D. Creatinine

Correct answer: C

Rationale: The correct answer is C: Amylase. Amylase levels are elevated in clients with acute pancreatitis due to inflammation of the pancreas. Elevated hemoglobin (choice A) is not typically associated with acute pancreatitis. Bilirubin (choice B) may be elevated in conditions affecting the liver, not specifically in acute pancreatitis. Creatinine (choice D) is a marker of kidney function and is not directly related to acute pancreatitis.

4. A client who has a new diagnosis of tuberculosis should be placed in which type of room to prevent the spread of airborne pathogens?

• A. Administer isoniazid by mouth daily.
• B. Place the client in droplet isolation.
• C. Wear a surgical mask when transporting the client.
• D. Place the client in a negative pressure room.

Correct answer: D

Rationale: Clients diagnosed with tuberculosis should be placed in a negative pressure room to prevent the spread of airborne pathogens. Option A is incorrect because administering isoniazid is a treatment for tuberculosis, not a preventive measure related to infection control. Option B is incorrect as droplet isolation is used for diseases transmitted through respiratory droplets, not airborne pathogens like tuberculosis. Option C is incorrect as wearing a surgical mask is not sufficient to prevent the spread of tuberculosis in healthcare settings; placing the client in a negative pressure room is the most effective measure.

5. A nurse in a pediatric clinic is reviewing the laboratory test results of a school-age child. Which of the following findings should the nurse report to the provider?

• A. Hgb 12.5 g/dL.
• B. Platelets 250,000/mm³.
• C. Hct 40%.
• D. WBC 14,000/mm³.

Correct answer: D

Rationale: The correct answer is D. A WBC count of 14,000/mm³ is elevated, indicating a potential infection or inflammation, and should be reported to the provider for further evaluation and management. Choices A, B, and C are within normal ranges and do not require immediate reporting as they indicate normal hemoglobin, platelet count, and hematocrit levels for a school-age child.

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