Nursing Elites

1. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?

• A. Pain related to ischemia
• B. Risk for altered elimination: constipation
• C. Risk for complication: dysrhythmias
• D. Anxiety related to pain

Correct answer: A

Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.

2. The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?

• A. After the acute phase of the disease has passed.
• B. As soon as the ability to move is lost.
• C. Once the patient enters the rehab unit.
• D. When the patient requests it.

Correct answer: B

Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.

3. When a nurse instructs a client with hearing loss about cleaning their new hearing aids, which statement indicates that the client understands the instructions?

• A. I use a damp cloth to clean the outside part of my hearing aids.
• B. I clean my hearing aids' ear molds with rubbing alcohol.
• C. I always keep the volume of my hearing aids turned up for better hearing.
• D. I remove the batteries from my hearing aids when not in use at night.

Correct answer: A

Rationale: The correct answer is A because cleaning the outside part of hearing aids with a damp cloth is an appropriate method. Rubbing alcohol can damage ear molds, so choice B is incorrect. Keeping the volume of hearing aids turned up high may lead to discomfort, making choice C incorrect. Removing batteries when not in use at night is good practice for battery life, but it does not directly relate to understanding cleaning instructions, so choice D is less relevant in this context.

4. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. Which action should the nurse implement?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: Using soft blankets to secure to the side rails provides better protection during a seizure as they are more secure and less likely to shift compared to pillows. This action helps prevent injury to the client by minimizing the risk of falling or hitting the side rails during a seizure. Choices B and C do not address the issue of using more secure materials. Choice D is inappropriate as it is important for the nurse to ensure the safety and well-being of the client by using the most appropriate protective measures.

5. A healthcare professional in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. Which of the following findings should the healthcare professional identify as an indication that the client has an infection?

• A. WBC 15,000/mm³
• B. Hemoglobin 12 g/dL
• C. Platelet count 300,000/mm³
• D. Sodium 140 mEq/L

Correct answer: A

Rationale: An elevated white blood cell count (WBC 15,000/mm³) is a common indicator of infection as the body increases WBC production to fight off pathogens. In conditions like infections, inflammation, or stress, the WBC count can rise. The other options, hemoglobin, platelet count, and sodium levels, are not typically specific indicators of infection. Hemoglobin measures the oxygen-carrying capacity of red blood cells, platelet count assesses clotting ability, and sodium levels indicate electrolyte balance.

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