Nursing Elites

1. An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?

• A. Have the UAP recheck the pulse and report back.
• B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
• C. Call the healthcare provider for further instructions.
• D. Immediately call the healthcare provider and prepare for transfer to critical care.

Correct answer: B

Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client’s cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.

2. A client receiving heparin therapy develops sudden chest pain and dyspnea. What should the nurse do first?

• A. Administer oxygen and elevate the head of the bed.
• B. Administer sublingual nitroglycerin as prescribed.
• C. Assess for signs of bleeding at the injection site.
• D. Administer a PRN dose of albuterol.

Correct answer: A

Rationale: In this scenario, the priority action for the nurse is to administer oxygen and elevate the head of the bed. These interventions help relieve dyspnea and chest pain, which can be indicative of a pulmonary embolism or other complications during heparin therapy. Administering nitroglycerin (Choice B) is not the initial priority in this situation as the client's symptoms are not suggestive of angina. Assessing for bleeding (Choice C) is important but not the first action needed to address chest pain and dyspnea. Administering albuterol (Choice D) is not indicated unless there are specific respiratory issues requiring it, which are not described in the scenario.

3. A client with hypertension is being educated on lifestyle changes by a nurse. Which recommendation is the most important to reduce blood pressure?

• A. Increase water intake
• B. Avoid alcohol consumption
• C. Exercise regularly
• D. Reduce sodium intake

Correct answer: D

Rationale: Reducing sodium intake is crucial in managing hypertension as high sodium levels can lead to fluid retention and increased blood pressure. While increasing water intake is beneficial for overall health, reducing sodium has a more significant impact on blood pressure. Regular exercise is important for cardiovascular health but does not have as direct an impact on blood pressure as sodium reduction. Avoiding alcohol is also important, but in terms of managing blood pressure, reducing sodium intake takes precedence.

4. A client with Parkinson's disease is prescribed levodopa/carbidopa. The nurse instructs the client to take the medication with meals. Which rationale should the nurse provide for taking the medication with food?

• A. It enhances the effectiveness of the medication
• B. It helps to improve absorption
• C. It prevents orthostatic hypotension
• D. It reduces gastrointestinal upset

Correct answer: D

Rationale: The correct answer is D: 'It reduces gastrointestinal upset.' Levodopa/carbidopa can cause nausea and other gastrointestinal side effects. Taking the medication with food can help reduce these side effects and improve the client's comfort. Choices A, B, and C are incorrect because taking the medication with food does not primarily enhance effectiveness, improve absorption, or prevent orthostatic hypotension. The main reason for advising to take the medication with meals is to minimize gastrointestinal upset.

5. A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

• A. Inform the healthcare provider
• B. Determine the client's need for pain medication
• C. Begin comfort measures
• D. Ensure all life-saving equipment is removed

Correct answer: B

Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.

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