Nursing Elites

1. What is the most appropriate action when a patient experiences a fall in the hospital?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to assess the patient for injuries. When a patient experiences a fall in the hospital, the immediate concern is to check for any injuries that may require urgent care. Calling for help can be done after assessing the patient to ensure appropriate assistance is provided. Documenting the fall is important for the patient's medical record, but it is not the most immediate action needed. Notifying the healthcare provider can come after the initial assessment to update them on the situation.

2. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

3. A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Administer nitroglycerin sublingually.
• C. Obtain a 12-lead ECG.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.

4. A nurse is assessing a client who has hyperthyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Dry skin.
• C. Cold intolerance.
• D. Tachycardia.

Correct answer: D

Rationale: The correct answer is D: Tachycardia. In clients with hyperthyroidism, tachycardia is a common finding due to the increased metabolic rate. Weight loss and heat intolerance are also expected due to the elevated metabolism. Choices A, B, and C (Weight gain, dry skin, cold intolerance) are not typical findings in hyperthyroidism, as the condition is associated with an overactive thyroid gland leading to an increase in metabolic functions.

5. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will limit my intake of protein to prevent kidney damage.
• B. I will avoid taking ibuprofen for my headaches.
• C. I will monitor my blood glucose level before meals and at bedtime.
• D. I will reduce my intake of carbohydrates to manage my blood sugar.

Correct answer: C

Rationale: The correct answer is C. Monitoring blood glucose levels before meals and at bedtime is crucial for managing type 2 diabetes mellitus. Option A is incorrect because limiting protein intake is not a primary focus for diabetes management. Option B is unrelated to diabetes management and focuses on pain relief. Option D mentions reducing carbohydrate intake, which is a common dietary recommendation for managing blood sugar levels, but it is not as specific as monitoring blood glucose levels at key times.

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