Nursing Elites

1. What is the initial action the nurse should take for a client who had a myocardial infarction (MI) and is experiencing restlessness, agitation, and an increased respiratory rate?

• A. Administer oxygen.
• B. Administer morphine sulfate.
• C. Notify the healthcare provider.
• D. Take the client's blood pressure.

Correct answer: A

Rationale: Administering oxygen is the priority action for a client experiencing restlessness, agitation, and an increased respiratory rate after a myocardial infarction (MI). This intervention helps ensure adequate oxygenation, improve cardiac function, and reduce the workload on the heart. Oxygen therapy takes precedence over administering medications like morphine sulfate or notifying the healthcare provider as it addresses the immediate need for oxygenation. Checking the blood pressure is also important but not as urgent as ensuring proper oxygen supply.

2. A client has a new prescription for nitroglycerin. Which of the following instructions should the nurse include?

• A. Store the medication in a cool, dry place.
• B. Take the medication as directed by the healthcare provider.
• C. Take the medication 30 minutes before meals.
• D. Take the medication at the first sign of chest pain.

Correct answer: D

Rationale: Instructing the client to take nitroglycerin at the first sign of chest pain is crucial for immediate relief of angina symptoms. Nitroglycerin is a fast-acting medication that helps dilate blood vessels, improving blood flow to the heart muscle. Therefore, prompt administration at the onset of chest pain is essential to alleviate anginal episodes effectively. Choices A, B, and C are incorrect because storing the medication properly, taking it as directed, or before meals are not specific instructions for managing acute anginal episodes, which require immediate action for symptom relief.

3. The nurse is teaching a client with coronary artery disease (CAD) about the risk factors for the disease. Which modifiable risk factor should the nurse emphasize?

• A. Family history
• B. Age
• C. Cigarette smoking
• D. Gender

Correct answer: C

Rationale: Cigarette smoking is a modifiable risk factor for coronary artery disease (CAD) as it can be changed or controlled to reduce the risk of developing CAD. Family history, age, and gender are non-modifiable risk factors that cannot be changed. Emphasizing the importance of quitting smoking can help the client reduce their risk of CAD and improve their overall cardiovascular health. Therefore, the correct answer is C. Choice A (Family history), B (Age), and D (Gender) are non-modifiable risk factors and not the focus of modifiable risk reduction strategies in CAD prevention.

4. The LPN/LVN is reinforcing discharge instructions to a client who has been prescribed nitroglycerin sublingual tablets for angina. Which statement by the client indicates a need for further teaching?

• A. I will keep my nitroglycerin tablets in the original glass bottle.
• B. I will sit or lie down when I take a nitroglycerin tablet.
• C. I will take a nitroglycerin tablet every 5 minutes if chest pain persists, up to a total of 3 tablets.
• D. I can swallow the nitroglycerin tablet with a glass of water if it does not dissolve quickly.

Correct answer: D

Rationale: The correct answer is D. Nitroglycerin sublingual tablets should not be swallowed; they must dissolve under the tongue to be effective. Choice A is correct as nitroglycerin tablets should be stored in their original glass container to prevent degradation. Choice B is correct as sitting or lying down when taking a nitroglycerin tablet helps prevent dizziness or fainting due to a sudden drop in blood pressure. Choice C is correct as taking a nitroglycerin tablet every 5 minutes for a maximum of 3 tablets is the correct protocol for managing angina symptoms.

5. The healthcare professional is assessing a client who presents with jaundice. Which assessment finding is most important for the healthcare professional to follow up on?

• A. Urine specific gravity of 1.03
• B. Frothy, tea-colored urine
• C. Clay-colored stools
• D. Elevated serum amylase and lipase levels

Correct answer: D

Rationale: Elevated serum amylase and lipase levels are indicative of pancreatitis, a serious condition that can manifest with jaundice. Timely follow-up is crucial to manage pancreatitis and its complications effectively in a jaundiced client. Choices A, B, and C are less critical in this scenario. Urine specific gravity within normal range, frothy tea-colored urine, and clay-colored stools can be associated with various conditions but are not directly indicative of pancreatitis, which is the most concerning condition associated with jaundice.

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