Nursing Elites

1. A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

• A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
• B. Turn the client prone to apply pressure on the abdominal wound to help staunch the bleeding.
• C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.
• D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Correct answer: C

Rationale: In a client with profuse bleeding from a gunshot wound to the abdomen, maintaining the client in a supine position is essential to manage blood pressure. This position helps in reducing diaphragmatic pressure and allows for proper visualization of the wound, aiding in prompt assessment and intervention to control the bleeding and stabilize the client's condition. Placing the client in a 45-degree Trendelenburg position (Choice A) could worsen the bleeding by increasing intrathoracic pressure and venous return, potentially leading to further hemorrhage. Turning the client prone (Choice B) may not be feasible in this situation and can delay essential interventions. Placing the client on the right side (Choice D) does not address the immediate need to manage the bleeding and stabilize the client's condition.

2. The client is reinforcing teaching for peripheral artery disease (PAD). Which statement by the client indicates correct understanding?

• A. I will keep my legs elevated on pillows while resting.
• B. I will avoid crossing my legs when sitting.
• C. I will wear tight compression stockings to improve circulation.
• D. I will apply heat to my legs to relieve pain and improve circulation.

Correct answer: B

Rationale: The correct answer is B. Crossing the legs can further impede blood flow in clients with PAD, worsening symptoms. Avoiding leg crossing helps maintain adequate blood flow and reduces the risk of complications associated with peripheral artery disease. Choices A, C, and D are incorrect because elevating the legs, wearing tight compression stockings, and applying heat can exacerbate symptoms in PAD by restricting blood flow or causing potential harm.

3. A client with heart failure is receiving digoxin. Which finding should indicate to the nurse that the client is experiencing digoxin toxicity?

• A. Constipation
• B. Blurred vision
• C. Bradycardia
• D. Dry cough

Correct answer: C

Rationale: Bradycardia is a hallmark sign of digoxin toxicity. Digoxin, a medication used to treat heart conditions, can lead to toxicity manifesting as bradycardia. Bradycardia occurs due to the drug's effect on slowing down the heart rate excessively. Constipation (Choice A) is not typically associated with digoxin toxicity. Blurred vision (Choice B) is more commonly linked to visual disturbances caused by digoxin, but it is not a defining sign of toxicity. Dry cough (Choice D) is not a recognized symptom of digoxin toxicity. It is crucial for the nurse to recognize the early signs of digoxin toxicity to prevent serious complications and provide appropriate interventions promptly.

4. A client with heart failure is prescribed an angiotensin-converting enzyme (ACE) inhibitor. What instruction should the nurse reinforce to the client?

• A. Take the medication at bedtime.
• B. Report a persistent dry cough.
• C. Increase potassium-rich foods in the diet.
• D. Avoid taking the medication with meals.

Correct answer: B

Rationale: The correct answer is B. A persistent dry cough is a common side effect of ACE inhibitors and should be reported to the healthcare provider. This symptom can indicate a potential issue with the medication that may require adjustment or discontinuation. Choices A, C, and D are incorrect. Taking the medication at bedtime or with meals is not a specific instruction for ACE inhibitors. Increasing potassium-rich foods in the diet is not directly related to ACE inhibitor therapy and may not be suitable for all patients.

5. A client with a history of angina pectoris reports chest pain after climbing stairs. What should be the nurse's first action?

• A. Administer oxygen.
• B. Administer nitroglycerin.
• C. Sit the client down and rest.
• D. Check the client's blood pressure.

Correct answer: C

Rationale: The correct action for a client experiencing anginal pain, like chest pain after climbing stairs, is to sit the client down and have them rest. Resting reduces myocardial oxygen demand, which can help relieve anginal pain. Administering oxygen or nitroglycerin may be appropriate interventions after the client has been seated and rested. Checking the client's blood pressure is important but not the immediate priority when a client is experiencing anginal pain. Therefore, the first action should be to sit the client down and allow them to rest.

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