Nursing Elites

1. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?

• A. Administer sublingual nitroglycerin
• B. Obtain a 12-lead electrocardiogram (ECG)
• C. Apply oxygen via nasal cannula
• D. Initiate continuous cardiac monitoring

Correct answer: C

Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.

2. The client has a chest tube. What is the most important action for the nurse to take?

• A. Ensure the chest tube remains unclamped at all times.
• B. Empty the chest tube every 2 hours.
• C. Keep the drainage system below the level of the chest.
• D. Assess for subcutaneous emphysema.

Correct answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

3. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?

• A. Place a sterile drape under the client's buttocks.
• B. Instruct the client to inhale and then exhale slowly.
• C. Discard the gloves and apply new sterile gloves.
• D. Apply a sterile lubricant to the end of the catheter.

Correct answer: D

Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.

4. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

• A. Provide the client with a list of reputable Internet sites that answer frequently asked questions about medications.
• B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
• C. Reassure the client that information about the medication is included in the written instructions.
• D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Correct answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or health care provider if any questions arise. Direct communication with healthcare professionals involved in the client's care is crucial to address any concerns promptly and accurately, ensuring the client's safety and understanding of the prescribed medication.

5. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

• A. Position the client on the right side of the bed in reverse Trendelenburg.
• B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
• C. Reposition the client in the Sims' position.
• D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

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