Nursing Elites

1. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated, and his blood pressure drops to 60/40. Which intervention should the nurse implement?

• A. Administer a second dose of nitroglycerin.
• B. Infuse a rapid IV normal saline bolus.
• C. Begin external chest compressions.
• D. Give a PRN antiemetic medication.

Correct answer: B

Rationale: In this scenario, the client's symptoms of nausea and a significant drop in blood pressure suggest a potential right ventricular infarction. The appropriate intervention for this situation is to infuse a rapid IV normal saline bolus. This fluid resuscitation helps improve cardiac output by increasing preload, which can be beneficial in right ventricular infarction. Administering a second dose of nitroglycerin may further lower blood pressure. External chest compressions are not indicated in this case as the client has a pulse. Providing an antiemetic medication does not address the underlying issue of hypotension and potential right ventricular involvement.

2. A female client reports that her hair is becoming coarse and breaking off, the outer part of her eyebrows has disappeared, and her eyes are all puffy. Which follow-up question is best for the nurse to ask?

• A. Is there a history of female baldness in your family?
• B. Are you under any unusual stress at home or work?
• C. Do you work with hazardous chemicals?
• D. Have you noticed any changes in your fingernails?

Correct answer: D

Rationale: The correct answer is D because the manifestations reported by the client, such as coarse hair, missing eyebrows, and puffy eyes, are indicative of hypothyroidism. Changes in the fingernails, such as brittle or pitted nails, can also be associated with hypothyroidism. Option A is incorrect as female baldness is not directly related to the reported symptoms. Option B is less relevant as stress typically does not cause these specific symptoms. Option C is also less relevant as exposure to hazardous chemicals would present with different symptoms.

3. An adult client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?

• A. Malignancy
• B. Infection
• C. Benign cyst
• D. Lymphadenitis

Correct answer: A

Rationale: The findings of a large, non-tender, hardened lymph node, especially in the absence of overlying tissue inflammation, are indicative of malignancy. These characteristics raise suspicion for cancer, prompting the need for further investigation. Choice B, Infection, is incorrect because infection would typically present as a tender and possibly swollen lymph node. Choice C, Benign cyst, is incorrect as cysts are usually soft and movable. Choice D, Lymphadenitis, is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes in response to an infection.

4. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which laboratory value should the nurse monitor closely?

• A. Serum calcium level of 9 mg/dl
• B. Serum potassium level of 4.5 mEq/L
• C. Serum creatinine level of 2.0 mg/dl
• D. Serum sodium level of 138 mEq/L

Correct answer: C

Rationale: The correct answer is C: Serum creatinine level of 2.0 mg/dl. In a client with ESRD receiving hemodialysis, serum creatinine should be closely monitored. Elevated creatinine levels indicate impaired kidney function. Monitoring serum calcium levels (Choice A), serum potassium levels (Choice B), and serum sodium levels (Choice D) is also important in clients with ESRD, but the most crucial indicator of kidney function in this case is serum creatinine.

5. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?

• A. Stop the transfusion and start a saline infusion.
• B. Administer antipyretics and continue the transfusion.
• C. Monitor the client’s vital signs every 15 minutes.
• D. Notify the healthcare provider and continue the transfusion.

Correct answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.

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