Nursing Elites

1. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

• A. Monitoring urine output
• B. Checking blood glucose levels
• C. Assessing for chest pain
• D. Monitoring electrolyte levels

Correct answer: C

Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.

2. A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?

• A. Decreased chest expansion
• B. Cyanosis
• C. Pursed-lip breathing
• D. Bradypnea

Correct answer: C

Rationale: Pursed-lip breathing is a common manifestation in clients with emphysema. It helps to increase the duration of exhalation and reduce air trapping, aiding in the management of the condition. Decreased chest expansion and bradypnea are not typically associated with emphysema. While cyanosis can occur in severe cases, pursed-lip breathing is a more specific and commonly observed sign of emphysema.

3. A client reports a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?

• A. Carbon monoxide poisoning
• B. Heat stroke
• C. Hypersensitivity reaction
• D. Oxygen toxicity

Correct answer: A

Rationale: When a client reports headache and vertigo after turning on the furnace for the first time, it suggests carbon monoxide poisoning. Carbon monoxide is an odorless, colorless gas that can be released by malfunctioning heating systems. Symptoms of carbon monoxide poisoning include headache, dizziness, weakness, nausea, and confusion. It is crucial for the nurse to suspect this condition promptly to ensure the client's safety and well-being.

4. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?

• A. Unequal pupils
• B. Hypertension
• C. Tympany upon chest percussion
• D. Confusion

Correct answer: D

Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.

5. A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?

• A. Take the medication with food to avoid stomach upset.
• B. Avoid exposure to sunlight while taking this medication.
• C. Report any numbness or tingling in extremities.
• D. Have liver function tests done regularly.

Correct answer: D

Rationale: Regular monitoring of liver function tests is crucial for clients taking isoniazid (INH) due to the potential risk of hepatotoxicity. Isoniazid can cause liver damage, and early detection through routine liver function tests can help prevent severe complications.

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