Nursing Elites

1. A client is expressing concern about extreme fatigue following an acute myocardial infarction. What is the best strategy to promote independence?

• A. Instruct the client to rest until fully recovered
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete self-care tasks
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence. This approach helps the client regain confidence and autonomy in performing self-care activities. Instructing the client to rest until fully recovered (Choice A) may lead to decreased muscle strength and independence. Assigning assistive personnel (Choice C) does not empower the client to actively participate in their care. Involving the client's family (Choice D) may provide support but does not directly encourage the client's independence.

2. What are the signs of an acute myocardial infarction?

• A. Chest pain radiating to the arm and shortness of breath
• B. Nausea, vomiting, and high fever
• C. Headache, confusion, and low blood pressure
• D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

3. A nurse is caring for a client who has pneumonia and new onset confusion. Which of the following actions should the nurse take first?

• A. Increase the client's oxygen flow rate
• B. Obtain the client's vital signs
• C. Administer an antibiotic
• D. Notify the provider

Correct answer: A

Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.

4. What is the priority nursing action for a patient with an acute asthma attack?

• A. Administer a bronchodilator
• B. Monitor oxygen saturation
• C. Position the patient in a high Fowler's position
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer a bronchodilator. During an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators are the first-line treatment for asthma attacks as they help dilate the bronchioles, allowing for better airflow. Monitoring oxygen saturation is important but not the priority when the patient is in distress. Placing the patient in a high Fowler's position can help with breathing but is not the initial priority. Calling for assistance can be done after initiating the appropriate treatment.

5. A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?

• A. Clamp the chest tube
• B. Maintain the drainage below the level of the chest
• C. Elevate the chest tube above chest level
• D. Avoid frequent dressing changes

Correct answer: B

Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.

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