Nursing Elites

1. What is the most important nursing action when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

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

• A. You should lie down before taking this medication.
• B. You should take this medication on an empty stomach.
• C. You should never take a double dose if you miss one.
• D. You should store this medication in its original container at room temperature.

Correct answer: A

Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to lie down before taking the medication. Nitroglycerin can cause a sudden drop in blood pressure leading to dizziness or fainting, so taking the medication while lying down helps prevent falls. Choice B is incorrect because nitroglycerin is usually taken on an empty stomach to enhance its absorption. Choice C is incorrect as taking a double dose of nitroglycerin can lead to low blood pressure and other adverse effects. Choice D is incorrect as nitroglycerin sublingual tablets should be stored in their original container at room temperature away from light and moisture, not in the refrigerator.

3. Which lab value should be monitored in patients receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT in patients receiving heparin therapy. Activated Partial Thromboplastin Time (aPTT) is crucial to assess the therapeutic effectiveness of heparin and to prevent bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy, not heparin. Platelet count (Choice C) monitoring is essential for detecting heparin-induced thrombocytopenia rather than assessing heparin therapy itself. Monitoring sodium levels (Choice D) is not directly related to heparin therapy monitoring.

4. A nurse is assessing a school-age child who has a urinary tract infection (UTI). Which of the following findings should the nurse expect?

• A. Periorbital edema.
• B. Decreased frequency of urination.
• C. Enuresis.
• D. Diarrhea.

Correct answer: C

Rationale: Enuresis is the correct finding to expect in a school-age child with a urinary tract infection. Enuresis, or involuntary urination, is a common symptom of UTIs in children. Periorbital edema (Choice A) is not typically associated with UTIs. Decreased frequency of urination (Choice B) is less likely in UTIs as there is often an increased urge to urinate. Diarrhea (Choice D) is not a common symptom of UTIs and is more indicative of gastrointestinal issues.

5. A client with a new diagnosis of hypertension is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will check my blood pressure at least once a week.
• B. I will avoid eating foods high in potassium.
• C. I should exercise for 30 minutes at least 5 days a week.
• D. I will take my medication only when I feel dizzy.

Correct answer: C

Rationale: The correct answer is C. Regular exercise is an essential component in managing hypertension. Exercising for at least 30 minutes a day, at least 5 days a week, can help control blood pressure. Checking blood pressure regularly (choice A) is important, but not as indicative of understanding the teaching as the commitment to regular exercise. Avoiding foods high in potassium (choice B) is not a typical recommendation for managing hypertension. Taking medication only when feeling dizzy (choice D) is incorrect and potentially dangerous; medications should be taken as prescribed by the healthcare provider.

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