Nursing Elites

1. A nurse is reviewing the medical record of a client who has a history of myocardial infarction. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. Heart rate of 88/min
• C. LDL cholesterol 110 mg/dL
• D. Respiratory rate of 16/min

Correct answer: D

Rationale: In a client with a history of myocardial infarction, a respiratory rate of 16/min should be reported to the provider. Changes in respiratory rate can indicate cardiac or pulmonary issues that need further evaluation. The other vital signs provided (blood pressure, heart rate, and LDL cholesterol level) are within normal limits and do not directly relate to potential complications following a myocardial infarction.

2. A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid using aspirin for pain.
• B. I will consume dairy products to increase my calcium intake.
• C. I will drink 1.5 to 2 liters of fluid each day.
• D. I will need to limit my intake of fiber.

Correct answer: A

Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.

3. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?

• A. The client's pulse oximetry level is 96%.
• B. The client develops hiccups.
• C. The ECG shows pacing spikes after the QRS complex.
• D. The client's heart rate is 90 beats per minute.

Correct answer: C

Rationale: The correct answer is C. Pacing spikes after the QRS complex indicate a malfunction of the pacemaker and should be reported. Choice A is not directly related to the pacemaker function. Choice B, hiccups, are common and not typically associated with pacemaker issues. Choice D, a heart rate of 90 beats per minute, is within the normal range and does not indicate a pacemaker malfunction.

4. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place food on the left side of the client's mouth when they are ready to eat
• B. Provide assistance with the client's ADLs
• C. Maintain the client in an upright position
• D. Place the client's left arm on a pillow while they are sitting

Correct answer: D

Rationale: Placing the client's left arm on a pillow while they are sitting helps prevent shoulder displacement and provides support for the limb post-stroke. This positioning is important to maintain proper alignment and prevent complications. Choices A, B, and C are incorrect because placing food on the left side of the mouth, providing total assistance with ADLs, and maintaining the client on bed rest do not directly address the specific needs related to unilateral paralysis and dysphagia post right hemispheric stroke.

5. What is the appropriate action for a patient experiencing chest pain?

• A. Administer aspirin
• B. Reposition the patient
• C. Check oxygen saturation
• D. Prepare for surgery

Correct answer: A

Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.

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