Nursing Elites

1. A client is experiencing chest pain. Which action should the nurse take first?

• A. Administer aspirin
• B. Provide oxygen
• C. Perform an ECG
• D. Administer nitroglycerin

Correct answer: D

Rationale: Administering nitroglycerin is the priority action when a client is experiencing chest pain as it helps alleviate the pain caused by reduced blood flow to the heart. Oxygen can be beneficial, but nitroglycerin takes precedence in this situation. Aspirin can also be given, but nitroglycerin is the priority. Performing an ECG can provide valuable information but is not the first action to take in this scenario.

2. While obtaining the health and medication history of a client with a respiratory infection, the nurse learns that the client developed a rash the last time she took an antibiotic despite not being aware of any allergies. What information should the nurse provide to the client?

• A. Document the exact medication taken
• B. Ignore the symptom
• C. Stop taking antibiotics
• D. Continue with the current medication

Correct answer: A

Rationale: The correct answer is to instruct the client to document the exact medication taken. This is crucial for preventing future allergic reactions. By knowing the specific antibiotic that caused the rash, healthcare providers can avoid prescribing it again, reducing the risk of an allergic response. Choice B, 'Ignore the symptom,' is incorrect as ignoring a potential allergic reaction can lead to more severe complications. Choice C, 'Stop taking antibiotics,' is not advisable without proper guidance from a healthcare provider. Choice D, 'Continue with the current medication,' is also not recommended when there is a history of a rash related to antibiotic use.

3. The nurse is assessing the patient for respiratory complications of immobility. What action should the nurse take?

• A. Auscultate the entire lung region to assess lung sounds.
• B. Assess the patient at least every 4 hours.
• C. Focus auscultation on the upper lung fields.
• D. Inspect chest wall movements primarily during the expiratory cycle.

Correct answer: A

Rationale: Auscultating the entire lung region is the most appropriate action when assessing a patient for respiratory complications related to immobility. This approach helps the nurse identify any abnormalities in lung sounds, such as diminished breath sounds or the presence of secretions. Assessing the patient at regular intervals (choice B) is important but does not specifically address the respiratory assessment needed in this situation. Focusing auscultation on the upper lung fields (choice C) may miss potential issues in other areas. Inspecting chest wall movements primarily during the expiratory cycle (choice D) is not the most effective way to assess lung sounds and identify respiratory complications.

4. A healthcare provider is assessing a patient with dehydration. Which finding indicates the patient's condition is worsening?

• A. Dry mucous membranes.
• B. Tachycardia and low blood pressure.
• C. Bradycardia and shallow respirations.
• D. Clear lung sounds.

Correct answer: B

Rationale: Tachycardia and low blood pressure are indicative of worsening dehydration in a patient. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased intravascular volume, while low blood pressure reflects inadequate perfusion due to decreased fluid levels. Bradycardia and shallow respirations are not typical findings in worsening dehydration, and clear lung sounds do not directly correlate with the severity of dehydration.

5. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

• A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
• B. Advance the stronger leg and the cane together to support the weaker leg
• C. Remove the rubber tip when using the cane
• D. Hold the cane on the right side to provide support for the weaker leg

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.

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