Nursing Elites

1. A client is experiencing chest pain and is prescribed nitroglycerin. What should the nurse assess before administering the medication?

• A. Monitor the client’s oxygen saturation level.
• B. Check the client’s heart rate and blood pressure.
• C. Evaluate the client’s level of consciousness.
• D. Assess the client's chest pain severity using a pain scale.

Correct answer: B

Rationale: Before administering nitroglycerin, it is crucial to check the client’s heart rate and blood pressure. Nitroglycerin can lower blood pressure and heart rate, so assessing these parameters is essential to prevent exacerbating hypotension or bradycardia. While monitoring the client’s oxygen saturation level is important in some situations, it is not the primary assessment needed before administering nitroglycerin. Evaluating the client’s level of consciousness is relevant for other conditions but not specifically necessary before giving nitroglycerin. Assessing chest pain severity using a pain scale is valuable for pain management but is not the priority assessment before administering nitroglycerin.

2. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?

• A. Increased TSH
• B. Increased thyroxine (T4)
• C. Decreased TSH
• D. Decreased T3

Correct answer: A

Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.

3. A nurse receives a report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reported that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first?

• A. Measure urinary output
• B. Assess for weakness or dizziness
• C. Increase IV fluids
• D. Check for vaginal bleeding

Correct answer: D

Rationale: Saturation of the perineal pad after a hysterectomy suggests excessive vaginal bleeding, which must be addressed immediately. Assessing for vaginal bleeding is the priority in this situation as it can lead to hypovolemic shock. Measuring urinary output, assessing for weakness or dizziness, and increasing IV fluids are important interventions but checking for vaginal bleeding takes precedence due to the risk of hemorrhage post-hysterectomy.

4. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?

• A. Administer prescribed nitroglycerin.
• B. Obtain a 12-lead electrocardiogram (ECG).
• C. Check the client's vital signs.
• D. Place the client on continuous telemetry.

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.

5. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?

• A. Carrots
• B. White bread
• C. Bananas
• D. Apples

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.

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