Nursing Elites

1. The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?

• A. Monitoring the client's vital signs every 4 hours
• B. Assessing the puncture site for bleeding
• C. Encouraging the client to ambulate early to prevent complications
• D. Providing the client with fluids to flush out the contrast dye

Correct answer: B

Rationale: Assessing the puncture site for bleeding is a critical assessment after a cardiac catheterization procedure. This is essential to detect and address any potential complications promptly, such as hemorrhage or hematoma formation. Monitoring vital signs, encouraging early ambulation, and providing fluids to flush out contrast dye are important aspects of post-cardiac catheterization care, but assessing the puncture site for bleeding takes precedence due to the immediate risk of complications such as severe bleeding that require immediate intervention.

2. A client with schizophrenia taking clozapine is being assessed by a nurse. Which of the following findings is the priority for the nurse to report to the provider?

• A. Elevated blood pressure
• B. Fever
• C. Weight gain
• D. Dry mouth

Correct answer: B

Rationale: The priority finding for the nurse to report to the provider is B: Fever. Fever can be an indication of agranulocytosis, a potentially life-threatening condition associated with clozapine. Agranulocytosis is characterized by a significant decrease in white blood cells, making the client susceptible to severe infections. Prompt reporting of fever is crucial to prevent serious complications. Elevated blood pressure (Choice A), weight gain (Choice C), and dry mouth (Choice D) are important to monitor but are not as immediately concerning as fever, which could indicate a severe adverse reaction requiring urgent medical attention.

3. A healthcare professional is assessing a client who has been taking levodopa/carbidopa for Parkinson's disease. Which of the following findings should the healthcare professional report to the provider?

• A. Dry mouth
• B. Urinary retention
• C. Bradykinesia
• D. Dizziness

Correct answer: C

Rationale: Bradykinesia is a cardinal symptom of Parkinson's disease characterized by slowness of movement. An increase in bradykinesia may indicate a decline in the client's condition and the need for adjustments in their medication regimen. Therefore, the healthcare professional should promptly report this finding to the provider for further evaluation and management. Choices A, B, and D are not directly related to the client's Parkinson's disease or the medication levodopa/carbidopa. Dry mouth is a common side effect of many medications, including anticholinergics, but not specifically levodopa/carbidopa. Urinary retention and dizziness are also not typically associated with levodopa/carbidopa use for Parkinson's disease.

4. The nurse is assisting in the care of a client experiencing an acute myocardial infarction (MI). Which medication would the nurse expect to be administered to help reduce myocardial oxygen demand?

• A. Aspirin
• B. Morphine
• C. Atropine
• D. Lidocaine

Correct answer: B

Rationale: In the context of an acute myocardial infarction (MI), morphine is administered to relieve pain and reduce myocardial oxygen demand. By alleviating pain and anxiety, morphine helps reduce oxygen demand on the heart, which is beneficial in the setting of an MI. Aspirin, commonly used for its antiplatelet effects, helps inhibit platelet aggregation and is crucial in the management of MI to prevent further clot formation. Atropine is a medication used to treat symptomatic bradycardia by increasing heart rate, not commonly indicated in the management of acute MI. Lidocaine is used for ventricular dysrhythmias and is not typically given to reduce myocardial oxygen demand in an acute MI scenario.

5. A healthcare professional is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the healthcare professional take?

• A. Prime the blood tubing with normal saline.
• B. Verify the client’s identity using two identifiers.
• C. Infuse the blood rapidly over 30 minutes.
• D. Obtain the client’s vital signs every 4 hours during the transfusion.

Correct answer: B

Rationale: Verifying the client’s identity using two identifiers is a critical patient safety measure to ensure the correct patient receives the blood transfusion. This process involves checking the patient's identity using at least two unique identifiers, such as name, date of birth, or medical record number, to prevent administration errors. Priming the blood tubing with normal saline is necessary to ensure there are no air bubbles in the tubing, but it is not the immediate action required before administering the blood. Infusing packed red blood cells over 30 minutes is generally too rapid and can lead to adverse reactions; a slower rate is recommended for safe administration. Obtaining vital signs every 4 hours during the transfusion is not frequent enough to monitor the client adequately for potential transfusion reactions or complications; vital signs should be monitored more frequently, especially during the initial phase of the transfusion.

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