Nursing Elites

1. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

• A. 1530 (3:30 PM)
• B. 1600 (4:00 PM)
• C. 1630 (4:30 PM)
• D. 1700 (5:00 PM)

Correct answer: C

Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.

2. A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?

• A. Ciprofloxacin
• B. Fluconazole
• C. Tobramycin
• D. Vancomycin

Correct answer: A

Rationale: In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.

3. A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?

• A. Bowel sounds
• B. Surgical dressing
• C. Temperature
• D. Oxygen saturation

Correct answer: D

Rationale: The priority assessment for a client being admitted to the surgical unit following a cholecystectomy is oxygen saturation. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and ventilation, especially after surgery. Hypoxia can have serious consequences and needs to be promptly addressed. While assessing bowel sounds, surgical dressing, and temperature are important, oxygen saturation takes precedence in this situation.

4. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

• A. Pain severity
• B. Wound drainage
• C. Tissue integrity
• D. Airway patency

Correct answer: D

Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.

5. A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?

• A. Rifampin
• B. Isoniazid
• C. Acyclovir
• D. Pyrazinamide

Correct answer: C

Rationale: Acyclovir is an antiviral medication used to treat herpes virus infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all commonly used in the treatment of tuberculosis. Therefore, the nurse should not plan to administer Acyclovir to a client with tuberculosis.

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