Nursing Elites

1. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?

• A. Assess the client's blood pressure and level of consciousness.
• B. Call the health care provider or the Rapid Response Team.
• C. Obtain a permit for an emergency temporary pacemaker insertion.
• D. Prepare to administer antidysrhythmic medication.

Correct answer: A

Rationale: The ECG strip shows sinus bradycardia, which is common in clients with an inferior wall MI. This rhythm can lead to decreased perfusion due to bradycardia and blocks. The most crucial initial action for the nurse is to assess the client's hemodynamic status, including blood pressure and level of consciousness. This assessment will help determine the immediate needs of the client. Calling the health care provider or the Rapid Response Team, obtaining a permit for a pacemaker insertion, or preparing to administer antidysrhythmic medication may be necessary based on the assessment findings, but the priority is to evaluate the client's current condition first.

2. During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?

• A. Dirty carpets requiring vacuuming
• B. Expired food found in the refrigerator
• C. Outdated medications stored in the kitchen
• D. Presence of multiple cats in the home

Correct answer: B

Rationale: The presence of expired food in the refrigerator is concerning as it raises safety issues for the client and indicates potential financial constraints preventing them from buying fresh food. The nurse should consider referring the client to services like Meals on Wheels or other home-based food programs to address this issue and ensure the client's nutritional needs are met.

3. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

• A. Assess the client's lung sounds.
• B. Call the Rapid Response Team.
• C. Have the client sit upright.
• D. Listen to the client's lung sounds.

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

4. A client with acute respiratory distress syndrome (ARDS) requires care planning. Which of the following interventions should be included in the plan?

• A. Administer low-flow oxygen continuously via nasal cannula.
• B. Encourage oral intake of at least 3,000 mL of fluids per day.
• C. Offer high-protein and high-carbohydrate foods frequently.
• D. Place in a prone position

Correct answer: D

Rationale: In acute respiratory distress syndrome (ARDS), placing the client in a prone position helps improve ventilation-perfusion matching and oxygenation. This position can optimize lung function and is a beneficial intervention for clients with ARDS. Administering low-flow oxygen via nasal cannula, encouraging oral intake of excess fluids, or offering high-protein and high-carbohydrate foods are not primary interventions for ARDS and may not directly address the respiratory distress experienced by the client.

5. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

• A. Urticaria
• B. Stridor
• C. Vomiting
• D. Hypotension

Correct answer: B

Rationale:

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