Nursing Elites

1. A client complaining of chest pain is prescribed an intravenous infusion of nitroglycerin (Nitro-Bid). After the infusion is initiated, the occurrence of which symptom warrants the nurse discontinuing an intravenous infusion of nitroglycerin?

• A. Frontal headache
• B. Orthostatic hypotension
• C. Decrease in intensity of chest pain
• D. Cool clammy skin

Correct answer: D

Rationale: The correct answer is 'Cool clammy skin.' This assessment finding indicates decreased cardiac output that could result from excessive vasodilation. Cool clammy skin is a sign of poor perfusion, suggesting that the blood pressure might be dropping too low. Discontinuing the nitroglycerin infusion is crucial to prevent further complications. Choice A, 'Frontal headache,' is a common side effect of nitroglycerin but not a reason to discontinue the infusion unless severe or persistent. Choice B, 'Orthostatic hypotension,' may occur as a side effect of nitroglycerin but does not necessarily warrant discontinuation unless severe. Choice C, 'Decrease in intensity of chest pain,' is actually an expected therapeutic response to nitroglycerin and indicates improved myocardial perfusion, so it is not a reason to stop the infusion.

2. What should the nurse do while caring for a client with an eating disorder?

• A. Encourage the client to cook for others
• B. Weigh the client daily and keep a journal
• C. Restrict access to mirrors
• D. Monitor food intake and behavior for one hour after meals

Correct answer: D

Rationale: The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.

3. What is the best position for a client immediately following a bilateral salpingooophorectomy?

• A. Fowler's
• B. Modified Sims
• C. Side lying
• D. Flat supine

Correct answer: C

Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (Choice A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (Choice B) is typically used for rectal examinations, not for post-surgical management. Flat supine (Choice D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.

4. A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has:

• A. no relation to the blood transfusion.
• B. graft-versus-host disease (GVHD).
• C. myelosuppression.
• D. an allergic reaction to a recent medication.

Correct answer: B

Rationale: In this scenario, the symptoms of fever, liver abnormalities, rash, and diarrhea in an immunocompromised client a month after a blood transfusion are indicative of graft-versus-host disease (GVHD). GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can manifest within a month of the transfusion. While choices 1 and 4 are plausible, it is crucial for the nurse to consider the possibility of GVHD in immunocompromised transfusion recipients due to the significant risk. Myelosuppression, choice C, typically presents with decreased blood cell counts and is not consistent with the symptoms described. An allergic reaction to medication, choice D, would present with different manifestations such as itching, hives, or anaphylaxis, which are not described in the scenario.

5. A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?

• A. Request a private room on the GYN floor
• B. Assign her to a private room on the postpartum unit
• C. Discharge her home as soon as her condition is stable
• D. Room her with another client who experienced a pregnancy loss

Correct answer: A

Rationale: In this situation, the most appropriate room assignment for the client who delivered a stillborn infant would be to request a private room on the GYN floor. This client needs privacy to grieve, and having a private space allows for family members to offer support. Placing her in a GYN unit ensures that she is away from the maternity unit's sights and sounds, which could be painful reminders for her. Assigning her to a postpartum unit may cause distress due to the presence of other mothers and newborns. Discharging her home too early may not allow her sufficient time for emotional and physical recovery. Rooming her with another client who experienced a pregnancy loss may not provide the necessary privacy and space she needs for her emotional well-being.

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