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. A client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy with alcohol.
• C. Replace the tracheostomy tube every week.
• D. Cover the tracheostomy with a wet cloth when sleeping.

Correct answer: A

Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.

3. A client with prostate cancer declines to discuss concerns after the provider discusses treatment options. What statement should the nurse make?

• A. I am available to talk if you should change your mind.
• B. It’s important to discuss your concerns with the provider.
• C. You need to make a decision about your treatment options.
• D. Your concerns will be addressed at a later time.

Correct answer: A

Rationale: Offering to talk later if the client changes their mind respects their current choice and keeps the dialogue open. Choice B is not the best response as it may pressure the client to share concerns. Choice C is incorrect as it imposes a decision on the client. Choice D does not acknowledge the client's feelings in the moment and postpones addressing concerns.

4. The healthcare provider retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the healthcare provider administer to the client?

• A. 0.75 mL
• B. 1 mL
• C. 0.8 mL
• D. 1.2 mL

Correct answer: C

Rationale: The correct dosage calculation is to divide the prescribed dose by the concentration of the medication to determine the volume needed. In this case, 3 mg (prescribed dose) divided by 4 mg/mL (concentration) equals 0.75 mL. Therefore, the healthcare provider should administer 0.75 mL of hydromorphone to the client. Choices A, B, and D are incorrect because they do not accurately calculate the required volume based on the prescription and concentration provided.

5. What action should a healthcare professional planning to insert an IV for an older adult client take?

• A. Place the client’s arm in a dependent position.
• B. Place the client’s arm in a flexed position.
• C. Elevate the client’s arm to the level of the heart.
• D. Use a tourniquet above the insertion site.

Correct answer: A

Rationale: The correct action for a healthcare professional planning to insert an IV for an older adult client is to place the client’s arm in a dependent position. This positioning helps with vein prominence and facilitates easier IV insertion by enhancing blood flow and distending the veins. Placing the arm in a flexed position or elevating it to the level of the heart can impede vein visualization and make insertion more challenging. Using a tourniquet above the insertion site is a step in the IV insertion process but is not the initial action to take when preparing for the procedure.

Similar Questions