Nursing Elites

1. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?

• A. Administer nitroglycerin sublingually.
• B. Administer 2L of oxygen via nasal cannula.
• C. Administer aspirin 325 mg orally.
• D. Obtain a 12-lead ECG.

Correct answer: D

Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.

2. A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. You should expect your urine to turn orange while taking this medication.
• C. This medication can cause you to gain weight.
• D. Take this medication with food to reduce gastrointestinal discomfort.

Correct answer: D

Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.

3. A client has a nasogastric tube and is receiving intermittent enteral feedings. Which of the following actions should the nurse take to prevent aspiration?

• A. Administer a bolus feeding over 10 minutes.
• B. Elevate the head of the bed to 45 degrees during feedings.
• C. Flush the tube with 10 mL of sterile water before feedings.
• D. Position the client on the left side during feedings.

Correct answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

4. A client with diabetes mellitus is being taught by a nurse about preventing long-term complications. Which of the following client statements indicates an understanding of the teaching?

• A. I will keep my blood glucose levels within the target range.
• B. I will check my feet daily for any open sores or wounds.
• C. I will consume foods that are high in fiber.
• D. I will monitor my blood pressure regularly.

Correct answer: B

Rationale: The correct answer is B because checking the feet daily for open sores or wounds is crucial in preventing complications like diabetic foot ulcers. While maintaining blood glucose levels within the target range (choice A) is important in managing diabetes, it does not specifically address long-term complications. Consuming foods high in fiber (choice C) is beneficial for glycemic control but does not directly relate to preventing long-term complications. Monitoring blood pressure regularly (choice D) is important in managing diabetes but is not as directly related to preventing long-term complications as checking for foot wounds.

5. A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?

• A. Constipation
• B. Blurred vision
• C. Fever
• D. Dry mouth

Correct answer: C

Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.

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