Nursing Elites

1. The nurse is caring for a client with a history of myocardial infarction who is complaining of chest pain. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer nitroglycerin sublingually as prescribed.
• C. Obtain an electrocardiogram (ECG).
• D. Assess the client's level of consciousness.

Correct answer: C

Rationale: Obtaining an electrocardiogram (ECG) is the first priority in assessing for ischemia or infarction in a client with chest pain and a history of myocardial infarction. This diagnostic test provides crucial information about the heart's electrical activity and helps in identifying any acute cardiac changes. Administering oxygen therapy and nitroglycerin can be important interventions, but obtaining an ECG takes precedence as it directly assesses the client's cardiac status. Assessing the client's level of consciousness is also essential, but in this scenario, assessing for cardiac indications through an ECG is the initial step.

2. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 94%
• C. Carbon dioxide level of 45 mmHg
• D. Respiratory rate of 20 breaths per minute

Correct answer: C

Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.

3. An 80-year-old male client with multiple chronic health problems becomes disoriented, agitated, and combative 24 hours after being admitted to the hospital. What nursing intervention is most important to include in this client's plan of care?

• A. Request a psychiatric consultation for the client.
• B. Reorient the client frequently to time, place, and person.
• C. Administer prescribed antipsychotic medications to reduce agitation.
• D. Obtain an order for a sitter to stay with the client.

Correct answer: B

Rationale: Reorienting the client frequently is the most important nursing intervention in this scenario. It helps reduce confusion and agitation, which are common symptoms of acute delirium in hospitalized elderly clients. Requesting a psychiatric consult (choice A) may be necessary if the reorientation does not improve the client's condition or if there are underlying psychiatric concerns, but reorientation should be attempted first. Administering antipsychotic medications (choice C) should not be the initial intervention as they can have adverse effects in elderly individuals. Obtaining a sitter (choice D) may provide support but does not directly address the client's disorientation and agitation.

4. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum calcium level

Correct answer: A

Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.

5. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?

• A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
• B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
• C. Push the undiluted dextrose slowly through the current IV infusion.
• D. Ask the pharmacist to add the dextrose to a TPN solution.

Correct answer: C

Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.

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