Nursing Elites

1. An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question best assists the nurse in discriminating pain caused by a non-cardiac problem?

• A. Can you describe the pain to me?
• B. Have you ever experienced this pain before?
• C. Does the pain get worse when you breathe in?
• D. Can you rate the pain on a scale of 1 to 10, with 10 being the worst?

Correct answer: C

Rationale: The correct answer is C. Pain that worsens with breathing in can indicate pleuritic chest pain, which is non-cardiac in nature. This specific question helps in differentiating non-cardiac causes from cardiac causes of chest pain, as cardiac pain typically does not worsen with breathing. Choices A, B, and D are less specific in discriminating between cardiac and non-cardiac chest pain.

2. The nurse is preparing to administer an intravenous dose of potassium chloride to a client with hypokalemia. The nurse should monitor for which potential complication?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hypernatremia
• D. Hypercalcemia

Correct answer: A

Rationale: When administering potassium chloride to a client with hypokalemia, the nurse should monitor for hyperkalemia. Potassium chloride supplementation aims to increase potassium levels in individuals with hypokalemia. However, excessive administration can lead to hyperkalemia, which can be a serious and potentially life-threatening complication. Monitoring potassium levels is crucial to prevent this adverse outcome. Hypokalemia (Choice B) is the condition being treated, so it is not a complication of treatment. Hypernatremia (Choice C) refers to high sodium levels and is not directly related to the administration of potassium chloride. Hypercalcemia (Choice D) is an elevated calcium level and is not a common complication associated with potassium chloride administration in hypokalemia.

3. A client is admitted to the hospital with a diagnosis of myocardial infarction (MI). Which diagnostic test is most likely to be ordered to confirm this diagnosis?

• A. Echocardiogram
• B. Electrocardiogram (ECG)
• C. Chest X-ray
• D. Complete blood count (CBC)

Correct answer: B

Rationale: An Electrocardiogram (ECG) is the primary diagnostic tool used to confirm a myocardial infarction. An ECG provides immediate information on cardiac function and can show characteristic changes indicative of a myocardial infarction, such as ST-segment elevation or depression. An echocardiogram (Choice A) is useful for assessing heart structure and function but is not typically used as the primary test for confirming an acute myocardial infarction. Chest X-ray (Choice C) may show certain changes in heart size or pulmonary congestion but is not the primary diagnostic test for MI. A Complete Blood Count (CBC) (Choice D) provides information about the cellular components of blood and is not specific to confirming a myocardial infarction.

4. The client with diabetes mellitus has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

• A. Restore skin integrity.
• B. Prevent infection.
• C. Promote healing.
• D. Improve nutrition.

Correct answer: B

Rationale: Preventing infection is crucial in clients with gangrene to halt the spread of infection and avert further complications. Infections can exacerbate tissue damage and lead to systemic complications, making infection prevention a priority in the care plan for this client. Restoring skin integrity and promoting healing may not be achievable goals until the infection is under control. Improving nutrition is important for overall health but may not be the priority when the immediate concern is preventing infection.

5. A client is being taught about the use of an albuterol inhaler. Which of the following instructions should be included?

• A. Use the inhaler every 4 hours around the clock.
• B. Shake the inhaler well before use.
• C. Rinse your mouth with water after each use.
• D. Use the inhaler while lying down.

Correct answer: B

Rationale: Shaking the inhaler well before use is a crucial step in ensuring proper medication delivery. This action helps disperse the medication evenly within the device, optimizing the effectiveness of each dose. It ensures that the client receives the intended amount of medication. The other options are incorrect: Option A suggests a fixed time interval for inhaler use, which may not be suitable for all clients and can lead to overuse. Option C, rinsing the mouth, is more relevant for corticosteroid inhalers to prevent oral thrush. Option D, using the inhaler while lying down, is not recommended as it may lead to improper drug delivery and is not the correct position for inhaler use.

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