Nursing Elites

1. The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

• A. Stay with the client throughout the infusion.
• B. Keep emergency resuscitation equipment at the bedside.
• C. Obtain the client's allergy history.
• D. Ask the client about past allergic reactions to medications.

Correct answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

2. A client with a history of myocardial infarction is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Echocardiogram

Correct answer: A

Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. This test provides immediate information about the heart's electrical activity. Choice B, Chest X-ray, is used to visualize the structures of the chest, including the heart and lungs, but it does not directly assess for cardiac ischemia. Choice C, Arterial blood gases (ABGs), measures the oxygen and carbon dioxide levels in the blood and assesses acid-base balance, which is not the primary concern in this scenario. Choice D, Echocardiogram, is an ultrasound of the heart that provides information about the heart's structure and function, but it is not the initial diagnostic test for assessing cardiac ischemia in this situation.

3. The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Elevated liver enzymes
• D. Elevated blood glucose level

Correct answer: C

Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.

4. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?

• A. Headache
• B. Prothrombin time (PT) of 15 seconds
• C. Elevated liver enzymes
• D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.

5. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

• A. Urine output of 20 ml/hour
• B. Blood pressure of 138/88
• C. Respiratory rate of 18 breaths/min
• D. Temperature of 99.8°F

Correct answer: A

Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.

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