Nursing Elites

1. What is the initial action for treating chest pain in acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Administer aspirin
• C. Check cardiac enzymes
• D. Obtain IV access

Correct answer: A

Rationale: The correct initial action for treating chest pain in acute coronary syndrome is to administer sublingual nitroglycerin. Nitroglycerin helps dilate blood vessels, reducing the workload on the heart and improving blood flow to the heart muscle. Administering aspirin can also be beneficial, but the priority is to address chest pain promptly. Checking cardiac enzymes and obtaining IV access are important steps but are not the initial actions needed to alleviate chest pain in acute coronary syndrome.

2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client's skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder to the client's skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

3. What medication should be administered first for wheezing due to an allergic reaction?

• A. Albuterol via nebulizer
• B. Cromolyn via nebulizer
• C. Methylprednisolone IV
• D. Aminophylline IV

Correct answer: A

Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction because it quickly opens the airways by relaxing the muscles around the airways. Cromolyn (choice B) is used more for prevention rather than immediate relief of symptoms. Methylprednisolone (choice C) and Aminophylline (choice D) are not the first-line treatments for acute wheezing due to an allergic reaction.

4. What is the preferred treatment for a patient with unstable angina admitted with chest pain?

• A. Administer sublingual nitroglycerin
• B. Establish IV access
• C. Auscultate heart sounds
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps vasodilate coronary arteries, improving blood flow to the heart, relieving chest pain, and preventing cardiac tissue damage. Establishing IV access (choice B) is important but not the preferred initial treatment for unstable angina with chest pain. Auscultating heart sounds (choice C) and obtaining cardiac enzymes (choice D) are relevant assessments but do not address the immediate symptomatic relief needed for a patient with unstable angina and chest pain.

5. What are the expected signs of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe headache and confusion
• C. Elevated blood pressure and bradycardia
• D. Bradycardia and altered pupil response

Correct answer: A

Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.

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