Nursing Elites

1. A nurse is caring for a client who has a pulmonary embolism. Which of the following findings indicates the effectiveness of the treatment?

• A. A chest x-ray reveals increased density in all lung fields.
• B. The client reports feeling less anxious.
• C. Diminished breath sounds are auscultated bilaterally.
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.

Correct answer: B

Rationale: The correct answer is B. In a client with a pulmonary embolism, improvement in anxiety levels can indicate the effectiveness of treatment as it suggests better oxygenation and perfusion. Choices A, C, and D do not directly reflect the effectiveness of treatment for a pulmonary embolism. Increased density in all lung fields on a chest x-ray may indicate worsening of the condition, diminished breath sounds suggest impaired lung function, and ABG results with a pH of 7.48, PaO2 of 77 mm Hg, and PaCO2 of 47 mm Hg do not specifically indicate treatment effectiveness for a pulmonary embolism.

2. A nurse is caring for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication?

• A. Hemoglobin
• B. Platelet count
• C. Prothrombin time (PT)
• D. International normalized ratio (INR)

Correct answer: D

Rationale: The correct answer is D, International normalized ratio (INR). INR is used to monitor the therapeutic effect of warfarin, an anticoagulant medication. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Monitoring the INR helps assess how well the medication is working to prevent blood clots. Choices A, B, and C are not specific indicators for monitoring the effectiveness of warfarin. Hemoglobin levels primarily assess the oxygen-carrying capacity of red blood cells, platelet count evaluates the clotting ability of blood, and PT measures the time it takes for blood to clot. While these values are important for overall health assessment, they do not directly reflect the anticoagulant effects of warfarin.

3. A client with hypertension is receiving discharge teaching from a nurse on managing blood pressure at home. Which of the following instructions should the nurse include?

• A. Take medication at bedtime.
• B. Check blood pressure once a week.
• C. Use a blood pressure cuff that fits snugly around the arm.
• D. Stop taking medication once blood pressure is within the normal range.

Correct answer: C

Rationale: The correct answer is C: 'Use a blood pressure cuff that fits snugly around the arm.' Using a properly fitting cuff is essential for accurate blood pressure measurements. Choice A is incorrect because the timing of medication administration should be individualized and not specified in the question. Choice B is incorrect as checking blood pressure once a week may not provide sufficient monitoring for a client with hypertension. Choice D is incorrect because stopping medication abruptly once blood pressure is normal can lead to rebound hypertension and complications.

4. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

5. What is the initial nursing action for a patient presenting with chest pain?

• A. Administer aspirin
• B. Reposition the patient
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.

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