Nursing Elites

1. A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?

• A. Contact the pharmacy and request the prescribed form of aspirin
• B. Instruct the client about the effects of the medication
• C. Administer the aspirin with a full glass of water or a small snack
• D. Withhold the aspirin until consulting with the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to take is to contact the pharmacy and request the prescribed form of aspirin. Enteric-coated medications are designed to dissolve in the intestine, not the stomach, to avoid irritation. Therefore, it is essential to ensure the client receives the correct form of aspirin as prescribed. Instructing the client about the effects of the medication (choice B) is not necessary at this point as the issue is related to the form of the aspirin. Administering the aspirin with a full glass of water or a small snack (choice C) is not appropriate as it does not address the need for the correct form of the medication. Withholding the aspirin (choice D) without consulting the healthcare provider is not advisable as it may lead to a delay in the client receiving the necessary medication.

2. During a community health fair, a nurse is providing education on the effects of smoking. What is the most important information to include?

• A. Smoking can lead to cosmetic issues like tooth staining.
• B. Smoking is a leading cause of preventable death worldwide.
• C. Smoking temporarily elevates mood and alertness.
• D. Smoking is an expensive habit.

Correct answer: B

Rationale: The correct answer is B: 'Smoking is a leading cause of preventable death worldwide.' This information is crucial as it highlights the severe health risks associated with smoking, emphasizing the importance of cessation for overall health. Choice A is incorrect because cosmetic issues like tooth staining are not as significant as the life-threatening consequences of smoking. Choice C is incorrect because although smoking may temporarily elevate mood and alertness due to nicotine, this does not outweigh the serious health implications. Choice D is incorrect as while smoking is indeed an expensive habit, the focus should be on the health-related consequences to stress the urgency of quitting.

3. The nurse is caring for a client with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

• A. Administer morphine for pain relief.
• B. Encourage the client to perform isometric exercises.
• C. Position the client flat in bed.
• D. Restrict fluid intake.

Correct answer: A

Rationale: Administering morphine is a priority intervention during the acute phase of myocardial infarction (MI). Morphine not only provides pain relief but also reduces myocardial oxygen demand, which is crucial in this situation. Choice B is incorrect because isometric exercises can increase myocardial oxygen demand and are not recommended during the acute phase of MI. Choice C is incorrect as elevating the head of the bed, not keeping the client flat, is preferred to reduce workload on the heart. Choice D is incorrect because fluid intake should be encouraged unless contraindicated, as adequate hydration is essential for cardiac function.

4. A client presents to the emergency department with symptoms of a myocardial infarction. What should the nurse administer immediately under doctor's orders?

• A. Aspirin to prevent further blood clotting
• B. High-flow oxygen
• C. Intravenous fluids
• D. Nitroglycerin

Correct answer: A

Rationale: The correct answer is A: Aspirin to prevent further blood clotting. Administering aspirin is crucial in the immediate management of a myocardial infarction as it helps prevent further blood clot formation, which is a key component in the treatment and prevention of myocardial infarction. Oxygen therapy (Choice B) is often provided, but aspirin takes precedence due to its role in reducing clot formation. Intravenous fluids (Choice C) may be needed but are not the immediate priority in this situation. Nitroglycerin (Choice D) is commonly used for chest pain relief in myocardial infarction but is not the first medication to be administered in this scenario.

5. A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)

• A. Portal hypertension.
• B. Sodium and water retention.
• C. Decreased serum albumin.
• D. All of the above

Correct answer: D

Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.

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