Nursing Elites

1. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

2. A young male client is admitted to rehabilitation following a right AKA (above-the-knee amputation) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his 'right foot is aching.' The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?

• A. Teach the client distraction techniques
• B. Provide a soft blanket to ease discomfort
• C. Administer prescribed pain medication
• D. Encourage discussion of feelings about the loss of his limb

Correct answer: D

Rationale: The client's report of pain in a missing limb is consistent with phantom limb pain, which can be distressing. Encouraging the client to discuss his feelings helps address the emotional and psychological aspects of the amputation and supports his overall recovery. Teaching distraction techniques (choice A) may provide temporary relief but does not address the underlying emotional distress. Providing a soft blanket (choice B) is not the priority when dealing with phantom limb pain. Administering pain medication (choice C) may not effectively manage phantom limb pain as it is more related to central nervous system changes rather than tissue damage.

3. The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?

• A. Elevated troponin levels
• B. Increased white blood cell count
• C. Increased lactate dehydrogenase (LDH)
• D. Elevated C-reactive protein (CRP)

Correct answer: A

Rationale: Elevated troponin levels are the most specific and sensitive indicator of myocardial infarction. Troponin levels increase within hours of an MI and remain elevated for several days. White blood cell count, lactate dehydrogenase (LDH), and C-reactive protein (CRP) are not specific markers for MI. An increased white blood cell count may indicate inflammation or infection, increased LDH levels can be seen in various conditions like liver disease or muscle injury, and elevated CRP is a general marker of inflammation rather than specific to MI.

4. A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?

• A. Administer prescribed diuretics
• B. Place the client in a supine position
• C. Restrict fluid intake immediately
• D. Increase the client's sodium intake

Correct answer: A

Rationale: The correct answer is A: Administer prescribed diuretics. Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. While placing the client in a supine position can help with breathing and fluid redistribution, administering diuretics takes precedence as it directly addresses fluid overload. Restricting fluid intake immediately may be necessary in some cases, but the immediate priority is to administer diuretics. Increasing the client's sodium intake would worsen fluid retention and is contraindicated in heart failure.

5. A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?

• A. Obtain an analgesic prescription.
• B. Administer an IV fluid bolus.
• C. Administer PRN antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: The correct first intervention for a client with adrenal crisis and hypotension is to administer an IV fluid bolus. In adrenal crisis, the body is deficient in cortisol, leading to hypotension. Fluid resuscitation helps stabilize the blood pressure. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering a PRN antipyretic (Choice C) is not indicated as the client's vital signs do not suggest fever. Covering the client with a cooling blanket (Choice D) is not appropriate for addressing hypotension in adrenal crisis.

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