Nursing Elites

1. A client with a recent myocardial infarction is prescribed a beta-blocker. What side effect should the nurse monitor for?

• A. Monitor the client for bradycardia.
• B. Check the client’s blood pressure for signs of hypotension.
• C. Monitor the client for signs of hyperglycemia.
• D. Monitor for signs of fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Check the client’s blood pressure for signs of hypotension.' Beta-blockers can lead to decreased heart rate, but bradycardia is not the primary side effect to monitor. Monitoring for bradycardia is more relevant when administering medications like digoxin. Hyperglycemia is associated with medications like corticosteroids, not beta-blockers. Fluid retention is a side effect seen with medications like corticosteroids or calcium channel blockers, not beta-blockers. Therefore, in a client taking a beta-blocker after a myocardial infarction, monitoring for hypotension is crucial due to the medication's mechanism of action.

2. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

3. A client is admitted with a large bowel obstruction. What finding should the nurse report immediately?

• A. Absence of bowel sounds in all four quadrants.
• B. Abdominal distention with a firm, rigid abdomen.
• C. Frequent, small, liquid stools.
• D. Nausea and vomiting that worsens after meals.

Correct answer: B

Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.

4. A client in the third trimester of pregnancy reports that she feels some 'lumpy places' in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

• A. Instruct the client to immediately see her provider for an evaluation
• B. Assess the fluid for signs of infection
• C. Explain that this normal secretion can be assessed at the next visit
• D. Recommend breast ultrasound to rule out abnormalities

Correct answer: C

Rationale: The yellowish fluid is likely colostrum, a normal finding in late pregnancy as the breasts prepare for lactation. It is common for women in the third trimester to experience 'lumpy places' in the breasts due to increased milk duct development. In this situation, the nurse should educate the client that these findings are normal physiological changes associated with pregnancy. Since the client has an upcoming appointment with her healthcare provider in two weeks, it is appropriate to reassure her that this can be further assessed during that visit. Instructing the client to immediately see her provider (Choice A) is unnecessary as this is a common finding in late pregnancy. Assessing the fluid for signs of infection (Choice B) is not warranted as colostrum leakage is a normal occurrence. Recommending a breast ultrasound (Choice D) is premature without further assessment by the healthcare provider.

5. A client is experiencing angina at rest. Which statement indicates a good understanding of the care required?

• A. I will notify the nurse if my chest pain is not relieved in 30 minutes.
• B. I will use nitroglycerin as needed, every 5 minutes, up to 3 doses.
• C. I will avoid physical activity until the pain subsides completely.
• D. I will take nitroglycerin 30 minutes before any physical activity.

Correct answer: B

Rationale: The correct answer is B. Using nitroglycerin as needed, every 5 minutes, up to 3 doses, is the appropriate management for angina at rest. This helps dilate blood vessels, improving blood flow to the heart. Choice A is incorrect because chest pain that persists at rest should be addressed immediately, not waiting for 30 minutes. Choice C is incorrect as avoiding physical activity is not a recommended approach during an angina episode. Choice D is incorrect because nitroglycerin should be used during chest pain episodes, not as a preventive measure before physical activity.

Similar Questions