Nursing Elites

1. The nurse is preparing a client for discharge following a myocardial infarction. What should the nurse prioritize in the discharge instructions?

• A. Warning signs of a potential heart attack
• B. Importance of medication adherence
• C. Follow-up appointment details
• D. All of the above

Correct answer: D

Rationale: When preparing a client for discharge after a myocardial infarction, the nurse should prioritize providing comprehensive instructions. This includes educating the client about warning signs of a potential heart attack to recognize symptoms early, stressing the importance of medication adherence for optimal recovery and prevention of further cardiac events, and ensuring understanding of follow-up appointment details for ongoing monitoring and care. All these aspects are crucial in preventing complications and promoting the client's well-being. Therefore, selecting 'All of the above' as the correct answer is the most appropriate choice. Choices A, B, and C are all essential components of a holistic discharge plan for a client post-myocardial infarction.

2. Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?

• A. Application of topical antibacterial cream
• B. Use of careful hand washing technique
• C. Administration of plasma expanders
• D. Limiting visitors to the burned client

Correct answer: B

Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.

3. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

• A. Increase the oxygen flow rate according to the prescription
• B. Encourage the client to perform pursed-lip breathing
• C. Prepare for emergency intubation
• D. Assess the client's oxygen saturation and breath sounds

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

4. A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?

• A. Decreased sexual libido
• B. Amenorrhea
• C. Quickening
• D. Nocturia

Correct answer: B

Rationale: Amenorrhea is the absence of menstrual periods and is a common early sign of pregnancy, typically reported by a client who is 6 weeks pregnant. Decreased sexual libido (Choice A) may or may not be experienced in early pregnancy, but it is not as specific as amenorrhea. Quickening (Choice C) refers to fetal movements felt by the mother, which usually occurs around 18-20 weeks of pregnancy, not at 6 weeks. Nocturia (Choice D) is waking up at night to urinate and is not typically associated with early pregnancy.

5. A client with a history of seizure disorder who is receiving phenytoin (Dilantin) is being discharged. Which instruction should the nurse provide?

• A. Take the medication at bedtime.
• B. Monitor drug levels regularly.
• C. Avoid alcohol while taking this medication.
• D. Take the medication at the same time every day.

Correct answer: B

Rationale: The correct answer is to instruct the client to monitor drug levels regularly. This is crucial for phenytoin (Dilantin) to ensure that the medication levels are within the therapeutic range and to prevent toxicity. Choice A, taking the medication at bedtime, is not specifically required for phenytoin administration. Choice C, avoiding alcohol, is generally a good practice with medications but is not as critical as monitoring drug levels for phenytoin. Choice D, taking the medication at the same time every day, is important for consistency but does not address the specific monitoring needs of phenytoin.

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