Nursing Elites

1. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

• A. Store the glasses in a labeled case
• B. Clean the glasses with hot water
• C. Clean the glasses with a paper towel
• D. Store the glasses on the bedside table

Correct answer: A

Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This ensures the safety of the glasses and helps in their proper identification when needed. Cleaning the glasses with hot water (Choice B) can damage them, and using a paper towel (Choice C) can scratch the lenses. Storing the glasses on the bedside table (Choice D) can lead to misplacement or damage. Therefore, the most appropriate action is to store the glasses in a labeled case.

2. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?

• A. Administer nitroglycerin sublingually.
• B. Administer 2L of oxygen via nasal cannula.
• C. Administer aspirin 325 mg orally.
• D. Obtain a 12-lead ECG.

Correct answer: D

Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.

3. A client who has a new prescription for levothyroxine is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. ''I will need to take this medication for the rest of my life.''
• B. ''I will take this medication with an antacid.''
• C. ''I should avoid eating foods that contain iodine.''
• D. ''You should store this medication in the refrigerator.''

Correct answer: A

Rationale: The correct answer is A: ''I will need to take this medication for the rest of my life.'' Levothyroxine is a lifelong medication for clients with hypothyroidism and should be taken as prescribed. Choice B is incorrect because levothyroxine should not be taken with antacids as they can interfere with its absorption. Choice C is incorrect as iodine-containing foods do not need to be avoided with levothyroxine. Choice D is incorrect because levothyroxine should be stored at room temperature, not in the refrigerator.

4. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min
• B. White blood cell count of 9,000/mm3
• C. Temperature of 37.8°C (100°F)
• D. Blood pressure of 118/78 mm Hg

Correct answer: C

Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.

5. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella roster. Which of the following information should the nurse include?

• A. Children who have varicella are contagious until vesicles are crusted
• B. Children who have varicella should receive the herpes zoster vaccination
• C. Children who have varicella should be placed in droplet precautions
• D. Children who have varicella are contagious 4 days before the first vesicle eruption

Correct answer: A

Rationale: The correct answer is A. Children with varicella are contagious until the vesicles crust over, which is important for preventing transmission. Choice B is incorrect as varicella and herpes zoster are caused by different viruses, so the varicella vaccine is given to prevent varicella, not herpes zoster. Choice C is incorrect because varicella is primarily spread through respiratory secretions, so airborne precautions are recommended, not droplet precautions. Choice D is incorrect as children with varicella are contagious even before the first vesicle eruption, not just 4 days before.

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