Nursing Elites

1. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:

• A. Preparing the client for a perfusion scan
• B. Attaching the client to a cardiac monitor
• C. Administering oxygen via nasal cannula
• D. Ensuring that the intravenous (IV) line is patent

Correct answer: C

Rationale: When a client who has just undergone surgery experiences sudden chest pain, dyspnea, and tachypnea, indicating possible pulmonary embolism, the immediate priority for the nurse is to administer oxygen via nasal cannula. This intervention aims to improve oxygenation and alleviate respiratory distress, which is crucial in the setting of a potential pulmonary embolism. Preparing the client for a perfusion scan is not the immediate priority as stabilizing the client's respiratory status comes first. While attaching the client to a cardiac monitor is important for monitoring, administering oxygen takes precedence in this situation. Ensuring IV line patency is relevant for overall client care but is not the priority when a client is experiencing respiratory distress requiring immediate intervention.

2. When preparing to examine a client’s skin using a Wood light, what should the nurse do to facilitate this procedure?

• A. Darken the examining room
• B. Administer a local anesthetic
• C. Obtain a signed informed consent
• D. Shave the skin and scrub it with povidone-iodine (Betadine)

Correct answer: A

Rationale: When using a Wood light to examine the skin, the nurse should darken the examining room. This is necessary because the Wood light emits long-wavelength UV light, which is better visualized in a darkened environment. Administering a local anesthetic (Choice B) is not needed for this procedure. Obtaining a signed informed consent (Choice C) is not directly related to using a Wood light for skin examination. Shaving the skin and scrubbing it with povidone-iodine (Betadine) (Choice D) is not required and may not be appropriate for this type of skin examination.

3. A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client?

• A. Pupil constriction
• B. Increased urine output
• C. Complaints of dry mouth
• D. Complaints of feeling sweaty

Correct answer: D

Rationale: The correct answer is D: 'Complaints of feeling sweaty.' Scopolamine, an anticholinergic medication, commonly causes the side effect of decreased sweating, not increased urine output or pupil constriction. While dry mouth is a possible side effect, it is less likely than the altered sweating pattern. Therefore, the nurse should monitor the client for complaints of feeling sweaty due to the potential side effect of decreased sweating associated with scopolamine.

4. What is the primary purpose of administering anticoagulants to a patient with atrial fibrillation?

• A. To reduce blood pressure.
• B. To prevent clot formation.
• C. To prevent arrhythmias.
• D. To reduce inflammation.

Correct answer: B

Rationale: The primary purpose of administering anticoagulants to a patient with atrial fibrillation is to prevent clot formation. Patients with atrial fibrillation are at an increased risk of forming blood clots in the heart, which can lead to stroke if they travel to the brain. Anticoagulants help to reduce this risk by inhibiting the clotting process. Therefore, choices A, C, and D are incorrect because anticoagulants do not primarily aim to reduce blood pressure, prevent arrhythmias, or reduce inflammation in patients with atrial fibrillation.

5. In a client with congestive heart failure, the nurse would be correct in withholding a dose of digoxin without specific instruction from the healthcare provider if the client's

• A. serum digoxin level is 1.5 ng/mL.
• B. blood pressure is 104/68 mmHg.
• C. serum potassium level is 3 mEq/L.
• D. apical pulse is 68/min.

Correct answer: C

Rationale: The correct answer is C. Hypokalemia can precipitate digitalis toxicity in individuals on digoxin, increasing the risk of dangerous dysrhythmias. A serum potassium level of 3 mEq/L is below the normal range (3.5 to 5.5 mEq/L) and indicates hypokalemia, which can potentiate the effects of digoxin. Choices A, B, and D are not directly related to the potential for digitalis toxicity. Serum digoxin level of 1.5 ng/mL is within the therapeutic range, blood pressure of 104/68 mmHg is not a contraindication for administering digoxin, and an apical pulse of 68/min is within the normal range and not a reason to withhold digoxin.

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