Nursing Elites

1. What is the appropriate action for a patient experiencing chest pain?

• A. Administer aspirin
• B. Reposition the patient
• C. Check oxygen saturation
• D. Prepare for surgery

Correct answer: A

Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.

2. A charge nurse is teaching a group of nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

• A. Place a belt restraint on a school-age child who has seizures.
• B. Secure wrist restraints to the bed rails for an adolescent.
• C. Apply elbow immobilizers to an infant with a cleft lip injury.
• D. Keep the side rails of a toddler's crib elevated.

Correct answer: D

Rationale: The correct use of restraints is crucial to ensure patient safety. Keeping the side rails of a toddler's crib elevated is a safe practice as it prevents falls and provides a level of protection without directly restraining the child. Placing a belt restraint on a child with seizures (Choice A) is inappropriate as it may restrict movement and cause harm during a seizure. Securing wrist restraints to bed rails for an adolescent (Choice B) is not recommended as it can lead to injuries and compromise circulation. Applying elbow immobilizers to an infant with a cleft lip injury (Choice C) is also incorrect as it does not address the issue of restraint and is not a standard practice in this situation.

3. A healthcare professional is reviewing a client's laboratory results. Which of the following values is a contraindication to the administration of heparin?

• A. Hemoglobin 13 g/dL
• B. Platelet count 50,000/mm³
• C. White blood cell count 6,000/mm³
• D. INR 2.5

Correct answer: B

Rationale: The correct answer is B: Platelet count 50,000/mm³. A platelet count of 50,000/mm³ increases the risk of bleeding, making heparin contraindicated. Platelets are essential for blood clotting, and a low count can lead to excessive bleeding. Choices A, C, and D are not contraindications to heparin administration. Hemoglobin level of 13 g/dL is within the normal range, white blood cell count of 6,000/mm³ is also normal, and an INR of 2.5 is within the therapeutic range for patients receiving heparin therapy.

4. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 72 hours.
• B. Monitor the client's blood glucose every 4 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Use sterile technique when changing the central line dressing.

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

5. A client with diabetes mellitus is being taught by a nurse about preventing long-term complications. Which of the following client statements indicates an understanding of the teaching?

• A. I will keep my blood glucose levels within the target range.
• B. I will check my feet daily for any open sores or wounds.
• C. I will consume foods that are high in fiber.
• D. I will monitor my blood pressure regularly.

Correct answer: B

Rationale: The correct answer is B because checking the feet daily for open sores or wounds is crucial in preventing complications like diabetic foot ulcers. While maintaining blood glucose levels within the target range (choice A) is important in managing diabetes, it does not specifically address long-term complications. Consuming foods high in fiber (choice C) is beneficial for glycemic control but does not directly relate to preventing long-term complications. Monitoring blood pressure regularly (choice D) is important in managing diabetes but is not as directly related to preventing long-term complications as checking for foot wounds.

Similar Questions