Nursing Elites

1. What is the initial intervention for a patient experiencing an allergic reaction?

• A. Administer antihistamines
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer antihistamines as the initial intervention for a patient experiencing an allergic reaction. Antihistamines work to block the effects of histamine, a substance released during an allergic reaction, helping to relieve symptoms such as itching, swelling, and hives. Corticosteroids (Choice B) are sometimes used in severe cases to reduce inflammation, but they are not the first-line treatment for an allergic reaction. Administering oxygen (Choice C) may be necessary if the patient is having difficulty breathing, but it is not the first intervention. IV fluids (Choice D) are typically given for conditions like dehydration or shock, not as the primary intervention for an allergic reaction.

2. What is the priority nursing intervention for a patient experiencing a myocardial infarction?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Administer morphine
• D. Prepare for surgery

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority nursing intervention for a patient experiencing a myocardial infarction because it helps reduce the risk of further clot formation. Aspirin is a common medication given during the early stages of a heart attack to prevent additional clotting. Administering nitroglycerin may also be indicated to help relieve chest pain by dilating blood vessels, but aspirin takes precedence due to its role in preventing clot progression. Administering morphine is not typically the first intervention in myocardial infarction as it can mask symptoms and delay other critical treatments. Surgery is not an immediate priority in the initial management of a myocardial infarction.

3. A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing. Which of the following foods should the nurse recommend?

• A. Bananas
• B. Fish
• C. White bread
• D. Chicken breast

Correct answer: D

Rationale: Corrected Rationale: Chicken breast is an excellent source of protein, which is essential for wound healing due to its role in tissue repair and regeneration. Fish is also a good source of protein, but chicken breast is a more commonly recommended option for wound healing due to its high protein content and lower fat content compared to some types of fish. Bananas and white bread, on the other hand, are not high-protein foods and do not provide the necessary nutrients for wound healing.

4. When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?

• A. Expel any air bubbles at the top of the prefilled syringe
• B. Massage the injection site to evenly distribute the medication
• C. Inject the medication into the lateral abdominal wall
• D. Administer an NSAID for injection site discomfort

Correct answer: C

Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.

5. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

• A. Diaphoresis
• B. Hypotension
• C. Urinary retention
• D. Tachycardia

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

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