Nursing Elites

1. A nurse is assessing a client who reports chest pain. Which of the following findings should cause the nurse to suspect a myocardial infarction?

• A. Pain improves with rest
• B. Pain radiates to the left arm.
• C. Pain worsens with deep breathing.
• D. Pain is relieved by antacids.

Correct answer: B

Rationale: The correct answer is B. Radiating pain, especially to the left arm, is a classic sign of myocardial infarction. Pain that radiates to the left arm indicates cardiac involvement, making it a significant finding. Choices A, C, and D are incorrect because chest pain that improves with rest, worsens with deep breathing, or is relieved by antacids is less likely to be associated with a myocardial infarction.

2. A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?

• A. Inhale the medication deeply for 3-5 seconds
• B. Exhale forcefully before inhaling
• C. Shake the MDI vigorously before use
• D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth

Correct answer: A

Rationale: Corrected Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs. Choice A is the correct instruction for the use of a metered-dose inhaler (MDI). Choice B, exhaling forcefully before inhaling, is incorrect as it can lead to decreased medication delivery. Choice C, shaking the MDI vigorously before use, is also incorrect as excessive shaking can cause the medication to clump. Choice D, holding the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth, is not recommended as it may lead to improper inhalation technique.

3. A client has been diagnosed with tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

• A. Contact precautions
• B. Airborne precautions
• C. Droplet precautions
• D. Protective environment

Correct answer: B

Rationale: Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client with TB under airborne precautions to prevent the transmission of the disease. Choice A, contact precautions, are used for diseases that spread by direct or indirect contact. Choice C, droplet precautions, are for diseases transmitted by large droplets. Choice D, protective environment, is used for clients who have compromised immune systems.

4. A client with diabetes is receiving education on foot care. Which of the following should be included in the teaching?

• A. Inspect feet daily for cuts and sores
• B. Soak feet in warm water daily
• C. Wear closed-toe shoes at all times
• D. Trim toenails straight across

Correct answer: A

Rationale: The correct answer is A: Inspect feet daily for cuts and sores. Clients with diabetes are at an increased risk of foot complications, so it is essential to check for any cuts, sores, or injuries daily to prevent infections and complications. Soaking feet in warm water daily (choice B) is not recommended as it can lead to skin breakdown. Wearing closed-toe shoes at all times (choice C) is not advisable as it can cause excessive pressure and friction. Trimming toenails straight across (choice D) is the correct method to prevent ingrown toenails, not trimming them in a rounded shape.

5. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?

• A. Massage the affected extremity
• B. Elevate the affected leg
• C. Apply cold packs to the affected leg
• D. Keep the leg dependent to increase circulation

Correct answer: B

Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.

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