Nursing Elites

1. What instruction should the nurse include for a client prescribed nitroglycerin for a myocardial infarction?

• A. Take the medication only when experiencing severe chest pain.
• B. Store the medication in a dark container to protect it from light.
• C. Take the medication before engaging in physical activity that may trigger chest pain.
• D. Limit nitroglycerin use to no more than three doses in 15 minutes.

Correct answer: D

Rationale: The correct answer is D: 'Limit nitroglycerin use to no more than three doses in 15 minutes.' This instruction is crucial to prevent excessive use, which can lead to severe hypotension and other complications. Choice A is incorrect because nitroglycerin should also be used preventatively, not only during severe chest pain. Choice B is irrelevant and not a necessary instruction for nitroglycerin use. Choice C is incorrect as nitroglycerin is typically taken to prevent chest pain rather than waiting for an activity that may trigger it.

2. A client with type 1 diabetes is found unconscious with a blood glucose of 40 mg/dL. What is the nurse's priority intervention?

• A. Administer a 50% dextrose bolus intravenously.
• B. Administer glucagon intramuscularly.
• C. Provide oral glucose gel.
• D. Recheck the blood glucose level in 15 minutes.

Correct answer: A

Rationale: The correct answer is to administer a 50% dextrose bolus intravenously. In unconscious clients with hypoglycemia, IV dextrose rapidly raises the blood glucose level. Glucagon would be a slower option and is typically used if IV access is unavailable. Oral glucose gel is not appropriate for an unconscious client as it requires swallowing and may cause aspiration. Rechecking the blood glucose level in 15 minutes delays immediate treatment and could lead to further deterioration.

3. A client with advanced chronic kidney disease (CKD) is scheduled for hemodialysis. Which dietary instruction should the nurse provide to the client?

• A. Limit fluid intake to prevent fluid overload
• B. Increase sodium intake to improve fluid balance
• C. Increase potassium intake to prevent hypokalemia
• D. Increase protein intake to promote healing

Correct answer: A

Rationale: The correct answer is A: 'Limit fluid intake to prevent fluid overload.' Clients with advanced chronic kidney disease are at risk of fluid retention, which can lead to complications like fluid overload and hypertension. Therefore, it is crucial to instruct the client to limit fluid intake. Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and hypertension in clients with CKD. Choice C is incorrect as increasing potassium intake can be dangerous for clients with CKD who may already have elevated potassium levels. Choice D is incorrect because while protein intake may need to be adjusted for clients on hemodialysis, the priority in this case is managing fluid intake.

4. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, 'I have had it with that client. I just can't do anything that pleases him. I'm not going in there again.' The nurse should respond by saying

• A. He has a lot of problems. You need to have patience with him.
• B. I will talk with him and try to figure out what to do.
• C. He is scared and taking it out on you. Let's talk to figure out what to do.
• D. Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.

Correct answer: C

Rationale: The correct response is to acknowledge the UAP's feelings while exploring the client's behavior. By stating, 'He is scared and taking it out on you. Let's talk to figure out what to do,' the nurse shows empathy and readiness to address the situation collaboratively. This approach helps maintain a therapeutic environment for both the UAP and the client. Choices A and D are dismissive and do not address the underlying issue or provide support. Choice B, while showing willingness to intervene, lacks the understanding of the client's potential fear and does not address the UAP's feelings.

5. A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?

• A. Obtain a urine sample from the bedpan.
• B. Insert an indwelling urinary catheter.
• C. Measure the client's oral temperature.
• D. Remove dressing and assess surgical site.

Correct answer: C

Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.

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