Nursing Elites

1. What recommendations should the nurse provide to a patient diagnosed with GERD?

• A. Avoid items like mint that increase gastric acid secretion
• B. Eat small, frequent meals
• C. Avoid eating 1 hour before bedtime
• D. Avoid black and red pepper

Correct answer: A

Rationale: The correct answer is A: 'Avoid items like mint that increase gastric acid secretion.' Mint can relax the lower esophageal sphincter, leading to increased gastric acid secretion and worsening GERD symptoms. Choice B is a good recommendation for GERD management as it helps prevent excessive stomach distension. Choice C is also a recommended practice to avoid reflux during sleep. Choice D, avoiding black and red pepper, is not directly linked to exacerbating GERD symptoms, so it is not the most relevant recommendation for a patient diagnosed with GERD.

2. What should the healthcare provider do if a patient presents with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Administer aspirin
• C. Obtain cardiac enzymes
• D. Get IV access and auscultate heart sounds

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority action in the treatment of chest pain in acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain. Aspirin can also be given to reduce clot formation, but nitroglycerin takes precedence in providing immediate relief. Obtaining cardiac enzymes and assessing heart sounds are important steps in the diagnostic process but do not address the immediate need to relieve chest pain and prevent cardiac tissue damage. Therefore, administering sublingual nitroglycerin is the most appropriate initial intervention for a patient presenting with chest pain and possible acute coronary syndrome.

3. What are the signs and symptoms of Increased Intracranial Pressure (IICP)?

• A. Irritability, confusion, restlessness
• B. Fatigue and SOB
• C. Changes in pupillary response
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Irritability, confusion, restlessness. These are common signs of Increased Intracranial Pressure (IICP) as they result from the increased pressure on brain tissue. Choices B, C, and D are incorrect. Fatigue and shortness of breath (SOB) are not typical symptoms of IICP. Changes in pupillary response can be seen in other conditions but are not specific to IICP. Elevated blood pressure is not a common sign of IICP.

4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?

• A. Pitting edema of bilateral lower extremities
• B. Hypoactive bowel sounds in all four quadrants
• C. Weight is the same as the day before
• D. Bilateral posterior lung sounds are diminished

Correct answer: A

Rationale: The correct answer is A: Pitting edema of bilateral lower extremities. Pitting edema can indicate fluid overload, which is a potential complication of TPN administration. Choice B, hypoactive bowel sounds, is more indicative of a gastrointestinal issue rather than a complication of TPN. Choice C, weight remaining the same, is expected to remain stable with proper TPN administration. Choice D, diminished lung sounds, is not directly related to TPN administration and is more suggestive of a respiratory issue.

5. What is the priority action when the nurse administers insulin for a misread blood glucose reading?

• A. Monitor for signs of hypoglycemia
• B. Monitor for hyperglycemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.

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