Nursing Elites

1. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include?

• A. Perform an ECG every 12 hours
• B. Place the client in a supine position while resting
• C. Draw a troponin level every 4 hours
• D. Obtain a cardiac rehabilitation consultation

Correct answer: D

Rationale: After an acute myocardial infarction, it is important to involve the client in cardiac rehabilitation to help them recover and manage their condition effectively. Performing an ECG every 12 hours is not necessary unless there are specific indications for it. Placing the client in a supine position may not be ideal as it can increase venous return, potentially worsening cardiac workload. Drawing troponin levels every 4 hours is excessive and not recommended as troponin levels usually peak within 24-48 hours post-MI and then gradually decline.

2. A healthcare provider is assessing a child who is being treated for bacterial pneumonia. The provider notes an increase in the child's glucose level. The provider should identify this finding as an adverse effect of which of the following medications?

• A. Methylprednisolone.
• B. Ondansetron.
• C. Guaifenesin.
• D. Amoxicillin.

Correct answer: A

Rationale: Correct. Methylprednisolone, a corticosteroid, can lead to increased glucose levels as an adverse effect. Ondansetron is an antiemetic and does not typically cause elevated glucose levels. Guaifenesin is an expectorant and is not associated with raising glucose levels. Amoxicillin is an antibiotic and does not affect glucose levels.

3. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 95%
• B. Blood pressure of 130/85 mm Hg
• C. Coughing up small amounts of sputum
• D. Absent gag reflex

Correct answer: D

Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.

4. A client with heart failure has a new prescription for furosemide. Which of the following instructions should the nurse include?

• A. You should weigh yourself once a week while taking this medication.
• B. You should eat foods rich in potassium while taking this medication.
• C. You should take this medication at bedtime.
• D. You should take this medication with food to avoid stomach upset.

Correct answer: B

Rationale: The correct answer is B. Clients taking furosemide, a potassium-wasting diuretic, should increase their intake of potassium-rich foods to prevent hypokalemia. Option A is incorrect because weight monitoring is crucial for furosemide due to fluid loss. Option C is incorrect as furosemide is usually taken in the morning to prevent nighttime diuresis. Option D is incorrect because furosemide is best taken on an empty stomach for better absorption.

5. A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has a fractured femur and reports feeling short of breath.
• B. A client who is postoperative and has abdominal distention.
• C. A client who is receiving IV fluids and has a temperature of 38.5°C (101.3°F).
• D. A client who has cancer and has been receiving radiation therapy.

Correct answer: A

Rationale: The correct answer is A. A client with a fractured femur and reports feeling short of breath is at risk for a fat embolism, which is a medical emergency. The nurse should assess this client first to rule out this serious complication. Choice B may indicate paralytic ileus, which is important but not immediately life-threatening compared to a fat embolism. Choice C has a fever, which indicates infection but is not as urgent as a potential fat embolism. Choice D, a client receiving radiation therapy, is not experiencing an acute, life-threatening complication that requires immediate assessment compared to a fat embolism.

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