Nursing Elites

1. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?

• A. Administer oxygen as prescribed
• B. Perform an ECG
• C. Obtain a detailed health history
• D. Monitor vital signs regularly

Correct answer: B

Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.

2. Which nursing activity is within the scope of practice for the practical nurse?

• A. Complete an admission assessment in the normal newborn nursery
• B. Discontinue a central venous catheter that has become dislodged
• C. Observe a client rotate the subcutaneous site for an insulin pump
• D. Monitor a continuous narcotic epidural for a postoperative client

Correct answer: C

Rationale: The correct answer is C: 'Observe a client rotate the subcutaneous site for an insulin pump.' This activity is within the scope of practice for a practical nurse as it involves observing and ensuring proper technique for using an insulin pump, which aligns with their training and responsibilities. Choices A, B, and D are beyond the typical scope of practice for a practical nurse. Completing an admission assessment for a newborn nursery is usually performed by a registered nurse. Discontinuing a dislodged central venous catheter and monitoring a narcotic epidural require advanced skills and knowledge, usually carried out by registered nurses or advanced practice nurses.

3. The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?

• A. Diminished breath sounds on the affected side.
• B. Pain at the procedure site.
• C. Blood-tinged sputum.
• D. Shortness of breath.

Correct answer: D

Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.

4. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take?

• A. Encourage the client to eat crackers and milk
• B. Administer a PRN dose of 10U of regular insulin
• C. Give the client crackers and milk
• D. Record the client's reaction in the diabetic flow sheet

Correct answer: C

Rationale: The correct action for the nurse to take when a client becomes shaky and diaphoretic after insulin administration, indicating hypoglycemia, is to provide the client with carbohydrates like crackers and milk. Carbohydrates help raise blood glucose levels quickly. Encouraging the client to eat crackers and milk (Choice A) is the appropriate immediate action to address the hypoglycemia. Administering more insulin (Choice B) would worsen hypoglycemia, and recording the reaction (Choice D) is important but not the immediate action needed to treat the hypoglycemia.

5. A client with a diagnosis of depression is prescribed an SSRI. What is the most important information the nurse should provide?

• A. Take the medication as prescribed.
• B. Avoid consuming grapefruit juice.
• C. Report any thoughts of self-harm immediately.
• D. Understand that improvement may take weeks.

Correct answer: C

Rationale: The most important information the nurse should provide to a client prescribed an SSRI for depression is to report any thoughts of self-harm immediately. SSRIs can increase suicidal ideation, especially at the beginning of treatment, so it is crucial to monitor for this and take appropriate actions. While it is important to take the medication as prescribed (Choice A), the immediate need for reporting self-harm ideation takes precedence. Avoiding grapefruit juice (Choice B) is a general precaution with certain medications but not as critical in this scenario. Understanding that improvement may take weeks (Choice D) is important for managing treatment expectations, but ensuring the client's safety in the context of suicidal ideation is the top priority.

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