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 in the care plan?

• 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, cardiac rehabilitation is crucial for the client's recovery. It helps improve the client's overall cardiovascular health, reduces the risk of future cardiac events, and promotes a healthy lifestyle. The other options do not directly address the importance of cardiac rehabilitation in the client's recovery process.

2. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

• A. Opening the patient’s window to the outside environment
• B. Turning on the patient’s room ventilator
• C. Opening the door of the patient’s room leading into the hospital corridor
• D. Failing to wear gloves when administering a bed bath

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

3. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

4. Which instrument is used for auscultation?

• A. Percussion hammer
• B. Audiometer
• C. Stethoscope
• D. Sphygmomanometer

Correct answer: C

Rationale: Auscultation involves listening to internal sounds in the body, such as heart and lung sounds. The instrument used for auscultation is a stethoscope, which allows healthcare providers to listen to these sounds. The percussion hammer is used to elicit sounds on the body, the audiometer is used to measure hearing ability, and the sphygmomanometer is used to measure blood pressure. Therefore, the correct answer is 'Stethoscope.'

5. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

• A. Low back pain.
• B. Dyspnea.
• C. Hypotension.
• D. Thready pulse.

Correct answer: B

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

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