Nursing Elites

1. What is the priority intervention for a patient with possible acute coronary syndrome?

• A. Administer nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with possible acute coronary syndrome as it helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart. This intervention is crucial in managing acute coronary syndrome and should be given promptly. Getting IV access may be necessary, but administering nitroglycerin takes precedence to alleviate symptoms and prevent further heart damage. Auscultating heart sounds and administering aspirin are important aspects of the assessment and treatment plan, but they are not the priority interventions in the acute phase of suspected acute coronary syndrome.

2. A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching?

• A. I can expect swelling in my hands and on my face.
• B. The amount of protein in my blood is high.
• C. I might have some pain and gas in my stomach from this condition.
• D. I will use a soft bristle toothbrush to prevent bleeding gums.

Correct answer: A

Rationale: The correct answer is A. Nephrotic syndrome leads to edema, especially of the face and dependent areas, due to the loss of protein in the urine. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is incorrect as using a soft bristle toothbrush is not directly related to the manifestations of nephrotic syndrome.

3. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?

• A. Monitor for hyperglycemia
• B. Monitor for signs of hypoglycemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: B

Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.

4. A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?

• A. Lower the height of the solution container
• B. Increase the flow of enema solution
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: A

Rationale: The correct action to relieve abdominal cramping after enema administration is to lower the height of the solution container. This adjustment slows down the flow rate of the enema solution, which can help reduce discomfort by decreasing the pressure on the patient's abdomen. Increasing the flow of the enema solution (Choice B) would exacerbate the cramping by introducing more solution quickly. Removing the enema tubing (Choice C) is not necessary to address the cramping, and stopping the procedure (Choice D) may not be needed if adjusting the height of the solution container can resolve the issue.

5. What signs indicate increased intracranial pressure (IICP)?

• A. Restlessness, irritability, and confusion
• B. Sudden onset of seizures
• C. Bradycardia and altered pupil response
• D. Loss of consciousness

Correct answer: A

Rationale: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These symptoms occur due to the brain's increased pressure within the skull. Sudden onset of seizures (Choice B) is not typically associated with increased intracranial pressure. Bradycardia and altered pupil response (Choice C) are signs of advanced or worsening IICP. Loss of consciousness (Choice D) is a late sign of increased intracranial pressure.

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