Nursing Elites

1. A nurse is caring for a client who has a prescription for metoprolol. For which of the following findings should the nurse withhold the medication?

• A. Heart rate 56/min.
• B. Oxygen saturation 93%.
• C. Respiratory rate 18/min.
• D. Blood pressure 118/74 mm Hg.

Correct answer: A

Rationale: The correct answer is A: Heart rate 56/min. Metoprolol, a beta blocker, should be withheld if the client's heart rate is below 60/min to prevent further bradycardia. Choices B, C, and D are within normal ranges and do not indicate a need to withhold metoprolol.

2. What are the signs and symptoms of a pulmonary embolism?

• A. Sudden shortness of breath
• B. Chest pain
• C. Cough with blood
• D. All of the above

Correct answer: D

Rationale: A pulmonary embolism can manifest with sudden shortness of breath, chest pain, and coughing up blood. These symptoms are classic presentations of a pulmonary embolism due to the blockage of blood flow to the lungs. Therefore, the correct answer is 'All of the above.' Each symptom alone can be seen in various other conditions, but when occurring together, they strongly suggest a pulmonary embolism. Sudden shortness of breath is due to decreased oxygenation, chest pain can result from the strain on the heart, and coughing with blood may indicate damage to the lung tissue. Choosing any single symptom would not encompass the full range of presentations seen in a pulmonary embolism.

3. What is an early sign that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.

4. What are the nursing interventions for a patient with neutropenia?

• A. Monitor for signs of infection and administer antibiotics
• B. Isolate the patient and provide a low-microbial diet
• C. Monitor vital signs and avoid unnecessary invasive procedures
• D. Encourage the patient to engage in social activities

Correct answer: A

Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.

5. What are the key nursing assessments for a patient receiving enteral feeding?

• A. Monitor gastric residual volume and check for abdominal distension
• B. Ensure the correct placement of the feeding tube
• C. Assess for signs of dehydration and electrolyte imbalances
• D. Elevate the head of the bed to prevent aspiration

Correct answer: A

Rationale: The correct answer is A: Monitor gastric residual volume and check for abdominal distension. These assessments are critical to evaluate the patient's tolerance to enteral feeding. Monitoring gastric residual volume helps determine gastric emptying, while checking for abdominal distension can identify complications like bowel obstruction. Choices B, C, and D are important aspects of enteral feeding care but are not the primary assessments. Ensuring the correct placement of the feeding tube is crucial for safety, assessing for signs of dehydration and electrolyte imbalances is essential for overall patient well-being, and elevating the head of the bed is vital to prevent aspiration. However, these are not the key assessments specifically related to enteral feeding.

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