Nursing Elites

1. A nurse is assessing a client who has a history of angina and reports chest pain. Which of the following actions should the nurse take first?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Obtain a 12-lead ECG.
• C. Administer nitroglycerin sublingually.
• D. Notify the provider.

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead ECG. In a client with a history of angina and reporting chest pain, the priority action is to assess for myocardial infarction, which is best done through an ECG. Administering oxygen, nitroglycerin, or notifying the provider can be important actions but obtaining an ECG takes precedence in evaluating the client's condition.

2. A nurse is providing discharge teaching to a client who has a new prescription for lisinopril. Which of the following client statements indicates an understanding of the teaching?

• A. I may experience a persistent cough while taking this medication.
• B. I should take this medication with food.
• C. I should increase my intake of potassium-rich foods.
• D. I should stop taking this medication if I develop a headache.

Correct answer: A

Rationale: The correct answer is A: 'I may experience a persistent cough while taking this medication.' Lisinopril is known to cause a persistent cough as a common side effect. This statement indicates that the client understands the potential side effect associated with the medication. Choice B is incorrect because lisinopril is typically taken on an empty stomach. Choice C is incorrect as increasing potassium-rich foods without healthcare provider guidance can lead to hyperkalemia. Choice D is incorrect because a headache is not a common reason to stop taking lisinopril.

3. How should a healthcare professional manage a patient with respiratory distress?

• A. Administer bronchodilators
• B. Administer oxygen
• C. Check oxygen saturation
• D. Reposition the patient

Correct answer: B

Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.

4. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

• A. Holding the newborn in an en face position
• B. Asking the father to change the newborn's diaper
• C. Requesting the nurse to take the newborn to the nursery so she can rest
• D. Viewing the newborn's actions as uncooperative

Correct answer: D

Rationale: The correct answer is D because viewing the newborn's actions as uncooperative may indicate the client is struggling to bond, requiring intervention. Choices A, B, and C do not raise concerns about the bonding process between the client and the newborn. Holding the newborn in an en face position is a positive interaction. Asking the father to change the newborn's diaper involves family participation in care. Requesting the nurse to take the newborn to the nursery so she can rest is a valid request for maternal self-care.

5. A nurse is caring for a client who is receiving chemotherapy. Which of the following findings should the nurse report to the provider?

• A. Alopecia
• B. Weight gain of 1 kg (2.2 lb) in 24 hours
• C. White blood cell count of 6,000/mm³
• D. Temperature of 37.2°C (99°F)

Correct answer: B

Rationale: The correct answer is B. A weight gain of 1 kg (2.2 lb) in 24 hours is concerning as it indicates fluid retention, which can be a sign of complications in clients receiving chemotherapy. Rapid weight gain can be associated with conditions like fluid overload or electrolyte imbalances, which need prompt medical attention. Choices A, C, and D are not typically immediate concerns related to chemotherapy. Alopecia (choice A) is a common side effect of chemotherapy, a white blood cell count of 6,000/mm³ (choice C) falls within the normal range, and a temperature of 37.2°C (99°F) (choice D) is slightly elevated but not a critical finding in this context.

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