Nursing Elites

1. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel (AP)?

• A. Client who has chronic obstructive pulmonary disease and needs guidance with incentive spirometry
• B. Client who has awoken following a bronchoscopy and requests a drink
• C. Client who had a myocardial infarction 3 days ago and reports chest discomfort
• D. Client who had a cerebrovascular accident 2 days ago and needs help toileting

Correct answer: D

Rationale: The correct answer is D because the client who had a cerebrovascular accident 2 days ago and needs help toileting is stable and the task is appropriate for delegation to an assistive personnel (AP). Choices A, B, and C involve clients with more complex care needs that require the expertise of a nurse. Choice A involves providing guidance with incentive spirometry, which requires specialized knowledge and assessment skills. Choice B involves a client who has just undergone a bronchoscopy, so close monitoring is essential to assess for any complications. Choice C involves a client who had a myocardial infarction 3 days ago and is reporting chest discomfort, which could indicate a potential cardiac issue requiring immediate nursing assessment and intervention.

2. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsening with deep breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

3. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his mother's room. What action should the nurse take?

• A. Notify security.
• B. Respectfully deny the grandparent’s request.
• C. Contact the mother for verification.
• D. Escort the grandparent and newborn to the room.

Correct answer: B

Rationale: The correct action for the nurse to take is to respectfully deny the grandparent's request. In healthcare settings, strict security protocols are in place to ensure the safety of newborns. Only individuals with proper identification bracelets are allowed to transport newborns to prevent unauthorized individuals from taking them. Contacting the mother for verification would be time-consuming and may not be feasible immediately. Escorting the grandparent and newborn without proper identification would violate security protocols and compromise the newborn's safety. Notifying security should be done only if there is a threat or concern for safety, which is not the case in this scenario. Therefore, the best course of action is for the nurse to respectfully deny the grandparent's request to uphold the safety and security measures in place.

4. A client has been prescribed nitroglycerin for chest pain. Which of the following should the nurse include in the teaching?

• A. Take one tablet every hour for chest pain.
• B. Store nitroglycerin tablets in a cool, dark place.
• C. Take nitroglycerin with food to reduce stomach upset.
• D. Take nitroglycerin with an antacid to prevent heartburn.

Correct answer: B

Rationale: The correct answer is B. Nitroglycerin tablets should be stored in a cool, dark place to maintain their potency. Storing them correctly ensures that they remain effective when needed. Choices A, C, and D are incorrect. Taking one tablet every hour is not the correct dosing regimen for nitroglycerin. Nitroglycerin is usually taken as needed at the onset of chest pain, with specific instructions from the healthcare provider. Taking nitroglycerin with food or antacids is not necessary, as it is usually placed under the tongue for rapid absorption.

5. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Offer advice on coping strategies
• B. Encourage the partner to ask for help when needed
• C. Discuss the importance of grieving alone
• D. Suggest the partner avoid talking about the loss

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

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