Nursing Elites

1. What is the most appropriate action when a patient experiences chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: Administering aspirin is the correct initial action when a patient experiences chest pain. Aspirin helps reduce the risk of clot formation and is a standard first-line treatment for chest pain related to possible cardiac issues. Administering nitroglycerin may be appropriate based on the underlying cause of chest pain, but aspirin is typically administered first. Repositioning the patient is not the primary intervention for chest pain, and preparing for surgery is not the immediate action required unless indicated by a healthcare provider after assessment.

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

• A. Take the medication with a full glass of water.
• B. Take the medication with food to prevent stomach upset.
• C. Take one tablet every 5 minutes, up to three doses, for chest pain.
• D. Swallow the tablet whole for the best effect.

Correct answer: C

Rationale: The correct instruction for a client with a new prescription for nitroglycerin sublingual tablets is to take one tablet every 5 minutes, up to three doses, for chest pain. This dosing regimen helps relieve chest pain associated with angina by promoting vasodilation. Option A is incorrect as nitroglycerin sublingual tablets should be placed under the tongue, not swallowed with water. Option B is incorrect because taking nitroglycerin with food may decrease its effectiveness. Option D is incorrect because nitroglycerin sublingual tablets are meant to be dissolved under the tongue, not swallowed whole.

3. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.

4. How should a healthcare professional assess for fluid overload in a patient with heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.

5. A nurse is assessing a client who has a chest tube and notes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client.
• B. Clamp the chest tube.
• C. Replace the drainage system.
• D. Apply a dressing over the insertion site.

Correct answer: D

Rationale: The correct action for the nurse to take when continuous bubbling is noted in the water seal chamber of a chest tube is to apply a dressing over the insertion site. Continuous bubbling indicates an air leak, and applying a dressing helps manage this issue by providing a seal. Clamping the chest tube or replacing the drainage system is not appropriate in this situation as it can lead to complications such as tension pneumothorax or inadequate drainage of the pleural space.

Similar Questions