Nursing Elites

1. A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?

• A. History of gastrointestinal bleeding
• B. Prothrombin time of 12 seconds
• C. Platelet count of 180,000/mm³
• D. Creatinine level of 1.0 mg/dL

Correct answer: A

Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.

2. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?

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

Correct answer: B

Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.

3. A nurse is teaching a client who is to undergo total knee arthroplasty about postoperative care. Which of the following instructions should the nurse include?

• A. Apply heat to the affected knee
• B. Avoid placing pillows under the knee
• C. Avoid moving the knee for 2-3 days
• D. Apply ice to the affected knee for 24-48 hours

Correct answer: D

Rationale: The correct answer is to apply ice to the affected knee for 24-48 hours. Applying ice helps to reduce inflammation and pain after knee surgery, promoting healing. Choice A is incorrect because heat is not recommended postoperatively, as it can increase swelling. Choice B is incorrect because pillows should be placed under the knee to keep it elevated. Choice C is incorrect because early mobilization is essential for preventing complications such as blood clots.

4. Which of the following interventions should the nurse implement for a client with hyperkalemia?

• A. Administer calcium gluconate
• B. Increase fluid intake to promote potassium excretion
• C. Administer a diuretic
• D. Administer sodium bicarbonate

Correct answer: A

Rationale: The correct intervention for a client with hyperkalemia is to administer calcium gluconate. Calcium gluconate helps counteract the effects of hyperkalemia by stabilizing the cardiac cell membrane. Increasing fluid intake (Choice B) may not effectively lower potassium levels. Administering a diuretic (Choice C) or sodium bicarbonate (Choice D) is not the primary treatment for hyperkalemia and may not address the immediate need to lower potassium levels.

5. When managing a physically assaultive client, the nurse's INITIAL priority is to

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control and prevent further loss of control
• D. Clear the immediate area of other clients to prevent harm

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

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