Nursing Elites

1. The client with a history of left-sided heart failure is exhibiting increasing shortness of breath and frothy sputum. What is the priority nursing action?

• A. Administer oxygen
• B. Encourage coughing and deep breathing
• C. Place the client in a supine position
• D. Notify the healthcare provider immediately

Correct answer: A

Rationale: Shortness of breath and frothy sputum are indicative of pulmonary edema, a serious condition that requires immediate intervention to improve oxygenation. Administering oxygen is the priority action to support the client's respiratory function and prevent further deterioration. Oxygen therapy helps increase the oxygen levels in the blood, alleviate respiratory distress, and support vital organ function. Prompt intervention with oxygen can help stabilize the client while further assessments and treatments are initiated. Encouraging coughing and deep breathing may worsen the client's condition by increasing respiratory effort. Placing the client in a supine position can further compromise breathing in a client with pulmonary edema. Notifying the healthcare provider is important but not the priority when the client's respiratory status is deteriorating.

2. A client diagnosed with coronary artery disease (CAD) reports chest pain radiating to the left arm. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. What is the next appropriate nursing action?

• A. Administer another dose of nitroglycerin.
• B. Notify the healthcare provider immediately.
• C. Have the client lie down and stay calm.
• D. Give the client aspirin 325 mg to chew.

Correct answer: A

Rationale: If chest pain persists after the first dose of nitroglycerin, it is appropriate to administer a second dose while continuing to monitor the client's response. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, relieving chest pain associated with coronary artery disease. Reassessing the client's response to a second dose is crucial before considering other interventions like contacting the healthcare provider or providing additional medications. Administering another dose of nitroglycerin aligns with the standard protocol for managing ongoing chest pain in clients with CAD.

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

• A. Take the medication with a full glass of water.
• B. Lie down for 30 minutes after taking the medication.
• C. Take the medication at bedtime.
• D. Avoid dairy products while taking the medication.

Correct answer: A

Rationale: When taking alendronate, it is important to take the medication with a full glass of water to prevent esophageal irritation. This helps ensure that the medication reaches the stomach and is properly absorbed. Lying down after taking alendronate can increase the risk of esophageal irritation, which is why it is recommended to stay upright for at least 30 minutes after taking the medication. Taking the medication at bedtime or avoiding dairy products are not specific instructions associated with alendronate administration. Therefore, the correct instruction to include is to take the medication with a full glass of water.

4. The nurse is caring for a client who has undergone a coronary artery bypass graft (CABG) surgery. Which action should the nurse take to prevent postoperative complications?

• A. Encourage the client to cough and deep breathe every 1 to 2 hours.
• B. Maintain the client in a supine position at all times.
• C. Keep the client on bed rest for the first 48 hours.
• D. Restrict the client's fluid intake to prevent overload.

Correct answer: A

Rationale: Encouraging the client to cough and deep breathe every 1 to 2 hours is crucial post-CABG surgery to prevent respiratory complications, such as atelectasis and pneumonia. These actions help to expand lung volume, clear secretions, and prevent the collapse of alveoli. Choices B, C, and D are incorrect because maintaining the client in a supine position at all times can lead to complications like decreased lung expansion, keeping the client on bed rest for the first 48 hours may increase the risk of thromboembolism, and restricting fluid intake postoperatively can lead to dehydration and electrolyte imbalances.

5. 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.

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