Nursing Elites

1. A healthcare professional is reviewing the medical record of a client who received their medications 1 hour ago. The client reports chest pain. This can be an adverse effect of what medication?

• A. Digoxin
• B. Albuterol
• C. Lisinopril
• D. Metoprolol

Correct answer: B

Rationale: The correct answer is B, Albuterol. Albuterol can cause chest pain as a side effect due to its beta-agonist effects, which can lead to chest discomfort. Digoxin (choice A) is not typically associated with causing chest pain. Lisinopril (choice C) and Metoprolol (choice D) are not known to commonly cause chest pain as a side effect.

2. A client is preparing for surgery wearing a necklace. What is the appropriate action?

• A. Remove the necklace and place it in a drawer
• B. Tape the necklace to the patient's skin
• C. Ask the patient for permission to lock it in a safe
• D. Ask the family to hold onto the necklace

Correct answer: C

Rationale: The appropriate action when a client is wearing a necklace before surgery is to ask the patient for permission to lock it in a safe. This is in line with hospital policy to secure valuables before entering surgery. Choice A is incorrect because simply placing the necklace in a drawer may not be secure. Choice B is incorrect as taping the necklace to the patient's skin can cause skin irritation and is not a standard practice. Choice D is incorrect because the responsibility for securing valuables typically lies with the healthcare team, not the patient's family.

3. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

4. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

• A. Straps with quick-release buckles attached to bed side rails.
• B. Attempts to distract the patient with television are unsuccessful.
• C. Bilateral radial pulses present, 2+, hands warm to the touch.
• D. Released from restraints, active range-of-motion exercises completed.

Correct answer: C

Rationale: The correct answer is C because documenting bilateral radial pulses being present, 2+, and hands warm to the touch is crucial when caring for a patient in restraints. This information helps in monitoring circulation and assessing the patient's well-being. Choices A, B, and D are incorrect because they do not provide essential information related to the patient's safety and well-being while in restraints.

5. A patient with a urinary catheter reports discomfort. What is the nurse's priority action?

• A. Ensure the catheter tubing is not kinked.
• B. Irrigate the catheter to relieve the discomfort.
• C. Change the catheter to a smaller size.
• D. Remove the catheter and replace it with a new one.

Correct answer: A

Rationale: The correct answer is to ensure the catheter tubing is not kinked. This is the priority action because a kinked tubing can obstruct urine flow, leading to discomfort and potential complications. It is essential to troubleshoot the current catheter first before considering other interventions. Irrigating the catheter (Choice B) may not address the underlying issue of kinking. Changing the catheter to a smaller size (Choice C) or removing and replacing it with a new one (Choice D) should only be considered if ensuring the tubing is unkinked does not resolve the discomfort.

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