Nursing Elites

1. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?

• A. Obtain a detailed medical history
• B. Administer nitroglycerin
• C. Conduct an ECG
• D. Administer morphine sulfate

Correct answer: B

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.

2. A nurse is preparing an in-service about family violence for a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

• A. Perpetrators of family-directed violence do not recognize their behavior as abnormal.
• B. Female clients who experience partner violence are at greater risk for chronic diseases.
• C. The victim's risk for homicide is greatest when they decide to leave the relationship.
• D. The level of violence increases over time in abusive relationships.

Correct answer: C

Rationale: The correct answer is C because the risk of homicide increases significantly when a victim decides to leave an abusive relationship. This is a crucial point to emphasize in educating healthcare professionals about family violence. Choice A is incorrect because perpetrators often do not acknowledge their behavior as abnormal. Choice B is incorrect as victims of partner violence are at greater risk for chronic, not acute, diseases. Choice D is incorrect as the level of violence tends to escalate rather than decrease over time in abusive relationships.

3. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notices clots in the client's urinary catheter and decreased urinary output. Which of the following actions should the nurse take?

• A. Administer an antispasmodic
• B. Irrigate the catheter with 0.9% sodium chloride irrigation
• C. Apply gentle manual pressure to the bladder
• D. Clamp the catheter tubing

Correct answer: B

Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation. This action helps clear the clots in the catheter and restore proper urine flow after a TURP. Administering an antispasmodic (Choice A) is not the appropriate action for clots in the catheter and decreased urinary output. Applying gentle manual pressure to the bladder (Choice C) or clamping the catheter tubing (Choice D) could potentially worsen the situation by causing bladder distention or preventing urine drainage.

4. A patient recovering from a stroke has difficulty swallowing. Which action should the nurse prioritize?

• A. Begin feeding the patient soft solids.
• B. Place the patient on NPO (nothing by mouth) status.
• C. Provide ice chips to help soothe the throat.
• D. Start the patient on a clear liquid diet.

Correct answer: B

Rationale: The correct answer is to place the patient on NPO (nothing by mouth) status. Patients recovering from a stroke with difficulty swallowing are at high risk for aspiration, which can lead to serious complications like aspiration pneumonia. Therefore, the priority is to keep the patient on NPO until a thorough evaluation by a healthcare provider is completed. Choice A is incorrect as feeding the patient soft solids can increase the risk of aspiration. Choice C is incorrect as providing ice chips may further compromise swallowing safety. Choice D is incorrect as starting the patient on a clear liquid diet can also increase the risk of aspiration in this scenario.

5. A client reports pain and swelling at the IV site. What should the nurse do first?

• A. Flush the IV line and continue the infusion.
• B. Stop the infusion and notify the healthcare provider.
• C. Increase the IV infusion rate to reduce discomfort.
• D. Apply a warm compress to the IV site and continue monitoring.

Correct answer: B

Rationale: The correct answer is B: Stop the infusion and notify the healthcare provider. Pain and swelling at an IV site can indicate infiltration or infection, which are serious complications. Stopping the infusion helps prevent further harm to the client, and notifying the healthcare provider promptly allows for appropriate assessment and intervention. Choice A is incorrect because flushing the IV line and continuing the infusion could exacerbate the issue. Choice C is incorrect as increasing the IV infusion rate is not the appropriate action for pain and swelling at the site. Choice D is incorrect because applying a warm compress may not address the underlying issue of infiltration or infection; it's crucial to stop the infusion and seek further guidance.

Similar Questions