Nursing Elites

1. After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?

• A. Irregular pulse rhythm
• B. Bile-colored emesis
• C. ST elevation in three leads
• D. Complaint of radiating jaw pain

Correct answer: C

Rationale: ST elevation in three leads is a critical finding that suggests myocardial infarction, requiring immediate attention. This finding indicates ischemia or injury to the heart muscle. Choices A, B, and D are not as critical in this scenario. Irregular pulse rhythm may be concerning but does not indicate an immediate life-threatening condition like myocardial infarction. Bile-colored emesis and complaint of radiating jaw pain are relevant but not as indicative of a myocardial infarction as ST elevation in three leads.

2. The home health nurse provides teaching about insulin self-injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen, which instruction should the nurse provide?

• A. Select a different injection site
• B. Continue with the insulin injection
• C. Keep the skin flat rather than bunched
• D. Lie down flat for better skin exposure

Correct answer: B

Rationale: Choosing to continue with the insulin injection is the correct instruction in this scenario because it allows the client to demonstrate proper technique and reinforces their learning. Selecting a different injection site (choice A) is not necessary if the client is injecting into the abdomen as it is a suitable site. Keeping the skin flat rather than bunched (choice C) is a good practice but is not the priority in this situation where the client is demonstrating the injection technique. Lying down flat for better skin exposure (choice D) is not required and may not be practical for the client during routine self-injections.

3. The adult client admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement?

• A. Take the client's temperature using another method.
• B. Raise the head of the bed to 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Check the blood pressure every five minutes for one hour.

Correct answer: A

Rationale: Taking the client's temperature using another method is the most appropriate action in this situation. A tympanic temperature of 94.6°F (34.8°C) is abnormally low and may not reflect the true core body temperature accurately. By using an alternative method, such as oral or rectal temperature measurement, the nurse can obtain a more reliable temperature reading. Raising the head of the bed (Choice B) is not directly related to addressing the low temperature. Asking the client to cough and deep breathe (Choice C) may be beneficial for respiratory function but does not address the temperature concern. Checking the blood pressure every five minutes for one hour (Choice D) is not the priority when the initial focus should be on accurate temperature assessment.

4. What is the most important content for the nurse to include in discharge teaching for a 51-year-old truck driver who smokes two packs of cigarettes a day, is 30 pounds overweight, and has been diagnosed with a gastric ulcer?

• A. Information about smoking cessation.
• B. Diet instructions for a low-residue diet.
• C. Instructions on a weight-loss program.
• D. The importance of increasing milk in the diet.

Correct answer: A

Rationale: The correct answer is A: Information about smoking cessation. Smoking is a significant risk factor for ulcer formation. It is crucial for the nurse to include smoking cessation information in the discharge teaching to help manage the gastric ulcer and prevent further complications. Choices B, C, and D are less relevant in this scenario. While diet modifications may be beneficial, addressing smoking cessation takes precedence due to its direct correlation with ulcer development.

5. A client scheduled for the surgical creation of an ileal conduit expresses anxiety and asks about having a drainage tube. How should the nurse respond?

• A. I will ask the provider to prescribe you an antianxiety medication.
• B. Would you like to discuss the procedure with your doctor once more?
• C. I think it would be nice to not have to worry about finding a bathroom.
• D. Would you like to speak with someone who has an ileal conduit?

Correct answer: D

Rationale: The most appropriate response for the nurse is to offer the client the opportunity to speak with someone who has undergone the same procedure. This allows the client to gain insight, ask questions, and share concerns with someone who has firsthand experience, which can help alleviate anxiety and promote a positive self-image. Seeking an antianxiety medication does not address the client's emotional concerns or promote a positive attitude towards the procedure. Discussing the procedure with the doctor again may provide more information but may not offer the same level of emotional support and understanding as speaking with someone who has lived through the experience. Commenting on the convenience of not having to search for a bathroom minimizes the client's anxiety and overlooks the emotional aspect of the client's concerns.

Similar Questions