Nursing Elites

1. A client is admitted with a possible myocardial infarction. Which laboratory test result is most indicative of a myocardial infarction?

• A. Serum creatine kinase (CK)
• B. Serum troponin
• C. Serum myoglobin
• D. C-reactive protein (CRP)

Correct answer: B

Rationale: Serum troponin is the most specific and sensitive indicator of myocardial infarction. Troponin levels rise within 3-4 hours after myocardial damage, peak at 10-24 hours, and remain elevated for up to 10-14 days. Creatine kinase (CK) and myoglobin can also be elevated in myocardial infarction, but troponin is more specific to cardiac muscle damage. C-reactive protein (CRP) is a marker of inflammation and is not specific for myocardial infarction.

2. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Increased abdominal girth

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

3. A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?

• A. Use bilateral eye patches while sleeping to prevent injury to the eyes.
• B. Wear sunglasses when outdoors to prevent photophobia.
• C. Apply cold compresses to reduce inflammation.
• D. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo.

Correct answer: D

Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.

4. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.

5. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

• A. Administer intravenous insulin as prescribed.
• B. Monitor the client's urine output.
• C. Administer intravenous fluids.
• D. Administer 50% dextrose IV push.

Correct answer: A

Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.

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