Nursing Elites

1. A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?

• A. Heart rate and blood pressure
• B. Blood glucose levels
• C. Respiratory rate
• D. Liver function tests

Correct answer: A

Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.

2. A 60-year-old male with type 2 diabetes mellitus tells the nurse that he is going to join a gym and start working out. Which information is most important for the nurse to obtain?

• A. Recent serum cholesterol levels
• B. Presence of calf pain during exercise
• C. Average weight gain or loss in the last year
• D. Exercise tolerance test with EKG results

Correct answer: B

Rationale: The most important information for the nurse to obtain in this scenario is the presence of calf pain during exercise. Calf pain during exercise could indicate peripheral vascular issues, such as peripheral artery disease, which is crucial to address before starting an exercise program. High cholesterol levels (choice A) may be important but are not as immediately relevant as assessing for peripheral vascular issues. Average weight gain or loss (choice C) may provide some insight into the patient's overall health status but is not as critical as assessing for potential vascular complications. An exercise tolerance test with EKG results (choice D) may be valuable in assessing cardiovascular fitness but is not as crucial as evaluating for peripheral vascular issues given the patient's symptoms.

3. When washing soiled hands, what should the nurse do after wetting the hands and applying soap?

• A. Rub hands palm to palm
• B. Interlace the fingers
• C. Dry hands with a paper towel
• D. Turn off the water faucet

Correct answer: A

Rationale: After wetting the hands and applying soap, the nurse should rub hands palm to palm. Rubbing hands palm to palm helps create friction and effectively clean the hands by spreading the soap and reaching all areas. Interlacing the fingers, drying hands with a paper towel, and turning off the water faucet should come after rubbing hands palm to palm in the handwashing process. Interlacing the fingers can be done to ensure the backs of the hands are cleaned, drying hands with a paper towel is the final step to ensure hands are dry, and turning off the water faucet helps save water.

4. A nurse is preparing to administer an intramuscular (IM) injection to a client. What is the most appropriate site to use for an IM injection in an adult?

• A. Dorsal gluteal muscle
• B. Vastus lateralis muscle
• C. Rectus femoris muscle
• D. Deltoid muscle

Correct answer: B

Rationale: The correct answer is B: Vastus lateralis muscle. The vastus lateralis muscle is a recommended site for IM injections in adults due to its size and accessibility. The dorsal gluteal muscle is not recommended for IM injections in adults due to the proximity to major nerves and blood vessels, increasing the risk of injury. The rectus femoris muscle is not a common site for IM injections in adults. The deltoid muscle is typically used for IM injections in small-volume medications or vaccines, especially in adults.

5. For a client with pneumonia, the prescription states, “Oxygen at liters/min per nasal cannula PRN difficult breathing.” Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of oxygen at high levels for extended periods.
• B. Administering a sedative at bedtime to slow the client’s respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.

Similar Questions