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 child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?

• A. Monitor the client’s skin for rash and lesions.
• B. Monitor for signs of increased intracranial pressure.
• C. Monitor the client’s blood pressure closely.
• D. Monitor for changes in heart rate and rhythm.

Correct answer: B

Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client’s skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.

3. During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?

• A. Administer a bronchodilator as prescribed.
• B. Check the client's oxygen saturation.
• C. Reassure the client and encourage deep breathing.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.

4. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.

5. A client with heart failure receiving furosemide develops muscle weakness. What is the nurse's priority action?

• A. Administer potassium supplements as prescribed.
• B. Monitor the client’s potassium levels.
• C. Instruct the client to increase their salt intake.
• D. Discontinue the furosemide.

Correct answer: B

Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias. Administering potassium supplements without monitoring the levels can lead to hyperkalemia, which has its own set of serious complications. Instructing the client to increase salt intake is not appropriate in this situation as it does not address the underlying electrolyte imbalance. Discontinuing furosemide abruptly can worsen heart failure symptoms; therefore, monitoring potassium levels and adjusting the treatment accordingly is the most appropriate action.

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