Nursing Elites

1. After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?

• A. Administer an anticoagulant.
• B. Warm the room and re-assess.
• C. Increase IV fluids.
• D. Notify the physician stat.

Correct answer: D

Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.

2. The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:

• A. Fearful situations
• B. Depression
• C. Delusions
• D. Anxiety

Correct answer: D

Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts. Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself. Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression. Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.

3. Teaching about the importance of avoiding foods high in potassium is most crucial for which client?

• A. a client receiving diuretic therapy
• B. a client with an ileostomy
• C. a client with metabolic alkalosis
• D. a client with renal disease

Correct answer: D

Rationale: Clients with renal disease are prone to hyperkalemia due to impaired kidney function, making it crucial for them to avoid foods high in potassium to prevent further complications. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk of hypokalemia. These individuals should actually consume foods high in potassium to replenish the electrolyte lost through diuresis, ileostomy output, or metabolic alkalosis.

4. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?

• A. Decrease the stimuli and observe frequently
• B. Administer the PRN sedative
• C. Call the physician immediately
• D. Administer the PRN pain medication

Correct answer: D

Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.

5. A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?

• A. "I became dizzy when I stood up."?
• B. "I was nauseated and began vomiting."?
• C. "The pain started in my chest and stopped after I sat down."?
• D. "The pain began with a migraine and progressed to numbness in my left arm."?

Correct answer: B

Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.

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