Nursing Elites

1. What is the most important nursing intervention for a patient with a suspected pulmonary embolism?

• A. Administer anticoagulants
• B. Administer oxygen
• C. Reposition the patient
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The most important nursing intervention for a patient with a suspected pulmonary embolism is to administer anticoagulants. Anticoagulants help prevent further clot formation in the patient's blood vessels, reducing the risk of complications such as worsening of the pulmonary embolism or development of new clots. Administering oxygen (Choice B) may be necessary to support the patient's oxygenation, but anticoagulants take precedence as they target the underlying cause of the pulmonary embolism. Repositioning the patient (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of patient care but are not the primary intervention for a suspected pulmonary embolism.

2. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?

• A. Increased urine output.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Facial weakness.

Correct answer: D

Rationale: Facial weakness is a common finding in clients with Guillain-Barré syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barré syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barré syndrome, making it an incorrect choice.

3. A nurse is providing discharge teaching to a client who has a new prescription for lithium. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Avoid eating foods that contain tyramine.
• C. Drink at least 2 liters of water each day.
• D. Take this medication in the evening before bedtime.

Correct answer: C

Rationale: The correct instruction for a client prescribed lithium is to drink at least 2 liters of water each day. This is important to prevent dehydration and reduce the risk of lithium toxicity. Option A is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Option B is unrelated to lithium and is more applicable to clients taking MAOIs. Option D is incorrect as lithium is typically taken in divided doses throughout the day to maintain therapeutic levels.

4. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator. Which of the following statements demonstrates understanding of the teaching?

• A. I will soak in the tub rather than showering.
• B. I will wear loose clothing around my ICD.
• C. I will stop using my microwave oven at home because of my ICD.
• D. I can hold my cellphone on the same side of my body as the ICD.

Correct answer: B

Rationale: The correct answer is B. Wearing loose clothing around the ICD is essential to avoid putting pressure on the device, which can interfere with its function. Choices A, C, and D are incorrect. Soaking in a tub rather than showering is not relevant to ICD care. Stopping the use of a microwave oven is not necessary with an ICD. Holding a cellphone on the same side as the ICD is not recommended as it can potentially interfere with the device.

5. A client at 14 weeks gestation reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?

• A. Describe your feelings to me about being pregnant.
• B. You should discuss your feelings with your provider.
• C. Have you discussed these feelings with your partner?
• D. When did you start having these feelings?

Correct answer: A

Rationale: The correct response is to use open-ended questions that allow the client to explore and express their feelings. Choice A encourages the client to describe their feelings, fostering open communication and providing an opportunity for the client to express themselves freely. Choices B and C do not directly address the client's feelings and may not promote open communication. Choice D focuses on the timing of the feelings rather than exploring the feelings themselves, making it a less therapeutic response.

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