Nursing Elites

1. A client who has a history of unstable angina is admitted to the emergency department with chest pain.

• A. Chest pain relieved by rest.
• B. Chest pain unrelieved after taking 3 sequential nitroglycerin tablets.
• C. Chest pain occurring only with exertion.
• D. Chest pain lasting less than 5 minutes.

Correct answer: B

Rationale: Chest pain unrelieved after taking 3 sequential nitroglycerin tablets indicates a possible myocardial infarction and requires immediate medical attention.

2. A client with chronic kidney disease is advised to follow a low-phosphorus diet. Which food should the client avoid?

• A. Milk
• B. Apples
• C. Carrots
• D. Rice

Correct answer: A

Rationale: Correct Answer: Milk. Milk is high in phosphorus and should be avoided in a low-phosphorus diet for clients with chronic kidney disease. Choice B (Apples), C (Carrots), and D (Rice) are not significant sources of phosphorus and can be included in moderation in a low-phosphorus diet. Apples and carrots are generally considered healthy choices for most individuals, while rice is a staple food that is low in phosphorus and can be part of a renal diet.

3. A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?

• A. Complete blood count (CBC)
• B. Activated partial thromboplastin time (aPTT)
• C. Prothrombin time (PT)
• D. International normalized ratio (INR)

Correct answer: B

Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.

4. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

• A. Collect the blood sample
• B. Assess radial pulse volume
• C. Apply pressure to the site
• D. Select another finger

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

5. A client with type 1 diabetes mellitus is experiencing nausea and vomiting. What is the most important instruction the nurse should provide?

• A. Stop taking insulin until feeling better
• B. Increase fluid intake to prevent dehydration
• C. Consume high-carbohydrate foods only
• D. Check blood glucose levels frequently

Correct answer: D

Rationale: The correct answer is to instruct the client to check blood glucose levels frequently. During illness, such as nausea and vomiting, managing blood glucose levels is crucial in clients with type 1 diabetes mellitus. Monitoring blood glucose levels frequently helps in adjusting insulin doses appropriately, preventing complications like hyperglycemia or hypoglycemia. Choice A is incorrect because stopping insulin abruptly can lead to serious complications. Choice B is important but not the most critical in this scenario. Choice C is incorrect as high-carbohydrate foods may further affect blood glucose levels negatively.

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