Nursing Elites

1. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include?

• A. Perform an ECG every 12 hours
• B. Place the client in a supine position while resting
• C. Draw a troponin level every 4 hours
• D. Obtain a cardiac rehabilitation consultation

Correct answer: D

Rationale: After an acute myocardial infarction, it is important to involve the client in cardiac rehabilitation to help them recover and manage their condition effectively. Performing an ECG every 12 hours is not necessary unless there are specific indications for it. Placing the client in a supine position may not be ideal as it can increase venous return, potentially worsening cardiac workload. Drawing troponin levels every 4 hours is excessive and not recommended as troponin levels usually peak within 24-48 hours post-MI and then gradually decline.

2. What is the best intervention for a patient presenting with respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Reposition the patient
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.

3. A nurse is assessing a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased level of consciousness.
• C. Tachycardia.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Tachycardia. In a client with increased intracranial pressure (ICP), tachycardia is a common finding. This is due to the body's compensatory mechanisms in response to the increased pressure. Bradycardia (choice A) is not typically associated with increased ICP and may indicate a different issue. Increased level of consciousness (choice B) is unlikely with increased ICP, as it often leads to altered mental status. Hyperactive bowel sounds (choice D) are not directly related to increased ICP and are more indicative of gastrointestinal issues.

4. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?

• A. Open sterile packages using the flap closest to your body first.
• B. Don sterile gloves before opening the sterile package.
• C. Avoid reaching over the sterile field.
• D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.

Correct answer: C

Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.

5. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

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