Nursing Elites

1. The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?

• A. Facial flushing
• B. A complaint of chest heaviness
• C. Heart rate increase of 10 beats/min
• D. Systolic blood pressure increase of 10 mm Hg

Correct answer: B

Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.

2. Which of the following terms refers to soft tissue injury caused by blunt force?

• A. contusion
• B. strain
• C. sprain
• D. dislocation

Correct answer: A

Rationale: A contusion is a soft tissue injury caused by blunt force. It is an injury that does not break the skin, caused by a blow, and characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition where the articular surfaces of the bones forming a joint are no longer in anatomical contact. Therefore, the correct answer is 'contusion' as it specifically relates to soft tissue injury caused by blunt force.

3. When administering intravenous electrolyte solution, which of the following precautions should the nurse take?

• A. Infuse hypertonic solutions cautiously.
• B. Mix no more than 60 mEq of potassium per liter of fluid.
• C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
• D. Monitor the client's digitalis dosage for potential adjustments due to IV calcium administration.

Correct answer: C

Rationale: When administering intravenous electrolyte solutions, it is crucial to prevent infiltration of calcium to avoid tissue necrosis and sloughing. Hypertonic solutions should be infused cautiously (Choice A) to prevent adverse effects. The correct amount of potassium to be mixed in a liter of fluid is no more than 60 mEq, making Choice B incorrect. While monitoring the client's digitalis dosage for potential adjustments due to IV calcium administration is important, the statement suggesting an increased dosage is incorrect as IV calcium diminishes digitalis's action, making Choice D incorrect.

4. A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:

• A. creamy, pink-tinged vaginal drainage.
• B. stomatitis.
• C. constipation.
• D. xerostomia.

Correct answer: A

Rationale: The correct answer is 'creamy, pink-tinged vaginal drainage.' This side effect persists for 1 to 2 months after the removal of a cervical implant. Diarrhea, not constipation, is usually a side effect of cervical implants. Stomatitis and xerostomia are local side effects of radiation to the mouth, not associated with cervical implants. Therefore, choices B, C, and D are incorrect.

5. A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care?

• A. Give the pain medication and return in an hour for further assessment to allow time for the medication to work.
• B. Complete the postpartum assessment and then give the client pain medication.
• C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided.
• D. Instruct the patient to do relaxation exercises to relieve her discomfort.

Correct answer: C

Rationale: Pain management is a priority, so the nurse should immediately provide pain medication. However, the nurse should conduct a quick assessment while administering the medication to ensure that a complication, such as hemorrhage, hasn't caused the increased pain. A complete assessment can wait until the pain subsides. Controlling pain will enable the client to move, eliminating other potential complications of delivery and facilitating bonding with the infant. Relaxation techniques can act as an adjunct therapy but by themselves are not usually effective for pain management during the early post-Caesarean period.

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