Nursing Elites

1. The LPN/LVN is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse should immediately ask the client which question?

• A. Are you having any nausea?
• B. Where is the pain located?
• C. Are you allergic to any medications?
• D. Do you have your nitroglycerin with you?

Correct answer: B

Rationale: In a client with angina pectoris, determining the location of chest pain is crucial for assessing the potential severity and cause. This information helps the nurse to further evaluate the nature of the pain and its probable origin, aiding in timely and appropriate interventions. Choices A, C, and D are not as immediately relevant as determining the location of the chest pain when assessing a client with angina pectoris.

2. The healthcare provider is monitoring a client following cardioversion. Which observation should be of the highest priority to the healthcare provider?

• A. Blood pressure
• B. Status of airway
• C. Oxygen flow rate
• D. Level of consciousness

Correct answer: B

Rationale: The status of the airway is the highest priority following cardioversion as it ensures proper oxygenation and helps prevent complications such as airway obstruction and respiratory distress. Maintaining a patent airway is crucial for the client's respiratory function and overall well-being immediately after cardioversion. Monitoring the airway ensures that the client can breathe effectively and minimizes the risk of hypoxia and other serious respiratory issues. While blood pressure, oxygen flow rate, and level of consciousness are also important parameters to monitor, they are secondary to ensuring a clear and patent airway for adequate oxygenation.

3. The nurse is preparing a client for discharge after a myocardial infarction (MI). Which instruction is most important for the nurse to reinforce with the client?

• A. Avoid engaging in sexual activity for at least 6 weeks.
• B. Engage in moderate physical activity daily.
• C. Take prescribed medications even if you feel well.
• D. Return to work only when medically cleared.

Correct answer: C

Rationale: The most critical instruction for a client after a myocardial infarction is to continue taking prescribed medications even if they feel well. This is essential in preventing another myocardial infarction or other complications. Discontinuing medications prematurely can be detrimental to the client's recovery and may increase the risk of further cardiovascular events. Choices A, B, and D are incorrect because engaging in sexual activity, physical activity, or returning to work are important aspects of the client's recovery, but not as crucial as ensuring medication compliance to prevent further cardiac issues.

4. The nurse is assisting with the care of a client diagnosed with heart failure. Which finding should the nurse report to the healthcare provider immediately?

• A. Weight gain of 2 pounds in 2 days
• B. Increased urination at night
• C. Mild shortness of breath on exertion
• D. Decreased appetite and fatigue

Correct answer: A

Rationale: A weight gain of 2 pounds in 2 days is concerning in a client with heart failure as it can indicate fluid retention and worsening of the condition. This finding requires immediate medical attention to prevent further complications. Increased urination at night (choice B) may be due to various reasons like diuretic use and is not an immediate concern. Mild shortness of breath on exertion (choice C) is expected in clients with heart failure and may not require immediate reporting. Decreased appetite and fatigue (choice D) are common symptoms in heart failure but are not as urgent as sudden weight gain.

5. A client is prescribed clopidogrel. What laboratory result should be monitored by the nurse?

• A. White blood cell count
• B. Creatinine
• C. Blood glucose
• D. Platelet count

Correct answer: D

Rationale: When a client is prescribed clopidogrel, monitoring the platelet count is essential. Clopidogrel is an antiplatelet medication that works by preventing blood clots. Monitoring the platelet count is crucial in assessing the risk of thrombocytopenia, a potential side effect of clopidogrel. Monitoring white blood cell count, creatinine, or blood glucose is not directly related to the action or side effects of clopidogrel, making choices A, B, and C incorrect.

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