Nursing Elites

1. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

2. A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?

• A. Hemoglobin level
• B. Platelet count
• C. Activated partial thromboplastin time (aPTT)
• D. Prothrombin time (PT)

Correct answer: B

Rationale: The correct answer is B: Platelet count. Enoxaparin can cause heparin-induced thrombocytopenia (HIT), making it crucial to monitor the platelet count for signs of thrombocytopenia. Monitoring the platelet count helps in early detection of this serious adverse effect. Choices A, C, and D are less relevant in this context. Hemoglobin level checks are more indicative of bleeding issues rather than thrombocytopenia caused by enoxaparin. Activated partial thromboplastin time (aPTT) and prothrombin time (PT) are less impacted by enoxaparin and are not typically used to monitor for HIT.

3. When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

• A. The client delivered a large baby
• B. She is a gravida 6, para 5
• C. The client had a cesarean delivery
• D. The client had a prolonged labor

Correct answer: B

Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.

4. Before a client with renal failure undergoes hemodialysis, what should the nurse assess?

• A. Check the client's potassium levels
• B. Review the client's medication list
• C. Assess the client's peripheral pulses
• D. Monitor the client's urine output

Correct answer: A

Rationale: The correct answer is to check the client's potassium levels. Potassium levels are crucial to assess before hemodialysis in a client with renal failure because hyperkalemia (high potassium) is a common complication in these patients. Hemodialysis aims to remove excess potassium from the blood, making it essential to monitor potassium levels to determine the need for appropriate interventions. Reviewing the client's medication list (Choice B) is important for overall care but is not as directly relevant to the immediate concerns before hemodialysis. Assessing peripheral pulses (Choice C) and monitoring urine output (Choice D) are important aspects of nursing assessment but are not as directly related to the specific preparation needed before hemodialysis in a client with renal failure.

5. The nurse is caring for a client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?

• A. Administering narcotics for pain relief
• B. Encouraging the client to increase fluid intake
• C. Applying oxygen therapy at a high flow rate
• D. Assisting the client with deep breathing exercises

Correct answer: C

Rationale: The correct answer is C: Applying oxygen therapy at a high flow rate. In clients with COPD, high levels of supplemental oxygen can suppress the hypoxic drive to breathe, leading to carbon dioxide retention and respiratory depression. Oxygen therapy must be administered cautiously to prevent worsening respiratory status. Administering narcotics for pain relief (Choice A) can be necessary but should be done judiciously. Encouraging fluid intake (Choice B) and assisting with deep breathing exercises (Choice D) are generally beneficial interventions for clients with COPD and should not require the same level of caution as high-flow oxygen therapy.

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