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. The nurse is caring for a client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention is most important for the nurse to implement?

• A. Encourage oral hydration
• B. Monitor for signs of dehydration
• C. Restrict fluid intake
• D. Administer IV fluids as prescribed

Correct answer: C

Rationale: In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia. The most crucial intervention is to restrict fluid intake to prevent further fluid overload and worsening of hyponatremia. Encouraging oral hydration (choice A) would exacerbate the condition by adding more fluids. Monitoring for signs of dehydration (choice B) is not appropriate as the client is at risk of fluid overload. Administering IV fluids (choice D) would worsen the hyponatremia and should be avoided.

3. A client with asthma is prescribed an inhaled corticosteroid. What teaching should the nurse provide?

• A. Rinse the mouth with water after using the inhaler.
• B. Take the medication only during asthma attacks.
• C. Avoid using the inhaler before exercise.
• D. Clean the inhaler with hot water after each use.

Correct answer: A

Rationale: The correct teaching the nurse should provide to a client prescribed an inhaled corticosteroid is to rinse the mouth with water after using the inhaler. This helps prevent oral fungal infections, a common side effect of inhaled corticosteroids. Choice B is incorrect because inhaled corticosteroids are usually used regularly, not just during asthma attacks. Choice C is incorrect as using the inhaler before exercise can actually help prevent exercise-induced bronchospasm. Choice D is incorrect because cleaning the inhaler with hot water after each use is not necessary and may damage the device.

4. A client on mechanical ventilation is experiencing high-pressure alarms. What action should the nurse implement first?

• A. Check the client's oxygen saturation.
• B. Assess the client's endotracheal tube for obstruction.
• C. Reposition the client to relieve pressure.
• D. Suction the client's airway.

Correct answer: B

Rationale: The correct answer is to assess the client's endotracheal tube for obstruction. When a client on mechanical ventilation experiences high-pressure alarms, the first action should be to check for any potential obstructions in the airway, which can trigger the alarms. Checking the oxygen saturation (Choice A) is important but not the priority when dealing with high-pressure alarms. Repositioning the client (Choice C) may be necessary later but should not be the initial action. Suctioning the client's airway (Choice D) should only be done after assessing for and addressing any obstructions in the endotracheal tube.

5. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?

• A. Assess the client's bowel sounds
• B. Administer prescribed pain medication
• C. Encourage the client to sit upright
• D. Provide clear fluids to the client

Correct answer: B

Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.

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