Nursing Elites

1. A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?

• A. Administer the infusion via an infusion pump
• B. Obtain the current serum potassium level
• C. Continuously monitor blood pressure
• D. Teach guided imagery to decrease pain

Correct answer: C

Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.

2. Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?

• A. Place a pulse oximeter on the heel
• B. Swaddle the infant in a warm blanket
• C. Record the findings on the flow sheet
• D. Check the vital signs in 15 minutes

Correct answer: C

Rationale: The correct action for the nurse to take in this scenario is to record the findings on the flow sheet. The newborn's axillary temperature, heart rate, and respiratory rate are within normal limits for a 3-hour-old newborn. Therefore, there is no immediate need for intervention or further assessment. Swaddling the infant in a warm blanket, placing a pulse oximeter on the heel, or checking the vital signs in 15 minutes are not necessary actions based on the normal assessment findings presented. These actions could potentially disrupt the newborn or lead to unnecessary interventions when the baby is stable.

3. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

4. When a UAP reports to the charge nurse that a client has a weak pulse with a rate of 44 beats per minute, what action should the charge nurse implement?

• A. Instruct the UAP to count the client's apical pulse rate for sixty seconds.
• B. Determine if the UAP also measured the client's capillary refill time.
• C. Assign a practical nurse (LPN) to determine if an apical radial pulse deficit is present.
• D. Notify the health care provider of the abnormal pulse rate and pulse volume.

Correct answer: D

Rationale: The correct action for the charge nurse to implement is to notify the health care provider of the abnormal pulse rate and pulse volume. A weak pulse with bradycardia (pulse rate of 44 beats per minute) requires immediate follow-up to investigate potential underlying issues. In this situation, it is crucial to involve the healthcare provider for further assessment and intervention. Instructing the UAP to count the client's apical pulse rate for sixty seconds (Choice A) may delay necessary actions. Determining capillary refill time (Choice B) is not directly related to addressing a weak pulse, and assigning an LPN to assess an apical radial pulse deficit (Choice C) is not as urgent as involving the healthcare provider.

5. The healthcare provider believes that a client who frequently requests pain medication may have a substance abuse problem. Which intervention reflects the healthcare provider's value of client autonomy over veracity?

• A. Administer the prescribed analgesic when requested
• B. Refer the client to a substance abuse program
• C. Collaborate with the healthcare provider to provide a placebo
• D. Document the frequency of medication requests

Correct answer: A

Rationale: Administering the prescribed analgesic when requested is the most appropriate intervention that reflects the healthcare provider's value of client autonomy over veracity. This action respects the client's right to manage their pain and avoids deception. Referring the client to a substance abuse program (Choice B) assumes a diagnosis without evidence and does not respect the client's autonomy. Collaborating to provide a placebo (Choice C) would involve deception, which goes against the value of veracity. Documenting the frequency of medication requests (Choice D) is important for the client's care but does not directly address the issue of respecting client autonomy over veracity.

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