Nursing Elites

1. A client with a history of hypertension is admitted with shortness of breath and chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Pulmonary function tests (PFTs)
• D. Arterial blood gases (ABGs)

Correct answer: A

Rationale: The correct answer is A: Electrocardiogram (ECG). An ECG should be performed first to assess for cardiac ischemia in a client presenting with shortness of breath and chest pain. This test helps in evaluating the electrical activity of the heart and can identify signs of myocardial infarction or other cardiac issues. Choice B, Chest X-ray, may be ordered after the ECG to assess for pulmonary conditions like pneumonia or effusions. Choice C, Pulmonary function tests (PFTs), are used to evaluate lung function and are not the primary diagnostic tests for a client with symptoms of cardiac origin. Choice D, Arterial blood gases (ABGs), may provide information about oxygenation but are not the initial test indicated for a client with suspected cardiac issues.

2. Which nursing intervention has the highest priority for a multigravida who delivered an hour ago?

• A. Maintain cold packs to the perineum for 24 hours.
• B. Assess the client's pain level frequently.
• C. Observe for appropriate interaction with the infant.
• D. Assess fundal tone and lochia flow.

Correct answer: D

Rationale: Assessing fundal tone and lochia flow is crucial in the immediate postpartum period to detect postpartum hemorrhage, a life-threatening complication. Monitoring these parameters allows for early identification of excessive bleeding, enabling prompt intervention. While maintaining cold packs to the perineum, assessing pain levels, and observing for appropriate interaction with the infant are important aspects of postpartum care, assessing fundal tone and lochia flow takes precedence due to its direct relevance to identifying and managing a potential emergency situation.

3. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?

• A. Headache
• B. Prothrombin time (PT) of 15 seconds
• C. Elevated liver enzymes
• D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.

4. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

• A. Cleanse the foot with soap and water and apply an antibiotic ointment
• B. Provide teaching about the need for a tetanus booster within the next 72 hours.
• C. Have the mother check the child's temperature every 4 hours for the next 24 hours
• D. Transfer the child to the emergency department to receive a gamma globulin injection

Correct answer: A

Rationale: The correct first action for the nurse to implement is to cleanse the foot with soap and water and apply an antibiotic ointment to prevent infection. In cases of puncture wounds like stepping on a rusty nail, the immediate concern is to reduce the risk of infection. Providing teaching about the need for a tetanus booster within the next 72 hours is important as well, but it should come after the wound is cleansed. Checking the child's temperature and transferring to the emergency department for a gamma globulin injection are not the immediate priorities in this scenario.

5. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?

• A. Auscultate the client's lungs for breath sounds
• B. Check the client's blood glucose level
• C. Monitor the client's bowel sounds
• D. Elevate the head of the bed to 45 degrees

Correct answer: D

Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.

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