Nursing Elites

1. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?

• A. Administer prescribed nitroglycerin.
• B. Obtain a 12-lead electrocardiogram (ECG).
• C. Check the client's vital signs.
• D. Place the client on continuous telemetry.

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.

2. Which foods should a healthcare provider recommend for a child with phenylketonuria (PKU) to avoid?

• A. Fresh fruit and vegetables
• B. Foods sweetened with aspartame
• C. Bread with honey
• D. Gluten-rich bread

Correct answer: B

Rationale: The correct answer is B: 'Foods sweetened with aspartame.' Children with PKU must avoid foods containing aspartame because it breaks down into phenylalanine, which can worsen their condition. Choice A, fresh fruit and vegetables, are generally healthy and safe for individuals with PKU. Choice C, bread with honey, is also safe unless the bread contains artificial sweeteners like aspartame. Choice D, gluten-rich bread, is not specifically problematic for individuals with PKU unless it contains aspartame or other substances high in phenylalanine.

3. The nurse reviews the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client support the diagnosis of tuberculosis?

• A. Mucopurulent cough and night sweats
• B. Fatigue and headache
• C. Persistent cough and weight gain
• D. Weight loss and fever

Correct answer: A

Rationale: A mucopurulent cough and night sweats are hallmark signs of active tuberculosis. These symptoms are key indicators of TB as the combination of a productive cough with night sweats is highly suggestive of the disease. Fatigue and headache (choice B) are nonspecific symptoms that can occur in many conditions and are not specific to TB. Persistent cough and weight gain (choice C) are not typical findings in tuberculosis. Weight loss and fever (choice D) can be present in TB, but the specific combination of mucopurulent cough and night sweats is more specific to the diagnosis.

4. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide?

• A. Avoid foods high in vitamin K, such as spinach.
• B. Report any signs of bleeding, such as bruising or nosebleeds.
• C. Take the medication on an empty stomach.
• D. Monitor for changes in blood pressure.

Correct answer: B

Rationale: The correct teaching for a client prescribed warfarin is to report any signs of bleeding, such as unusual bruising, nosebleeds, or blood in the urine or stool. Warfarin is an anticoagulant that increases the risk of bleeding, so it is crucial for the client to promptly report any bleeding-related symptoms for evaluation by a healthcare provider. Choices A, C, and D are incorrect. Avoiding foods high in vitamin K, such as spinach, is more relevant for clients taking warfarin to maintain consistent vitamin K intake. Warfarin should be taken with food to avoid gastrointestinal upset, so taking it on an empty stomach is not recommended. Monitoring for changes in blood pressure is not directly related to warfarin therapy; instead, the focus should be on monitoring for signs of bleeding.

5. In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?

• A. Pulse oximetry
• B. Blood glucose
• C. Arterial blood gases
• D. Serum electrolytes

Correct answer: B

Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.

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