Nursing Elites

1. What is the priority nursing action for a patient with shortness of breath?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.

2. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

3. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?

• A. Obtain the client's vital signs.
• B. Ensure the client's IV access is patent.
• C. Prime the IV tubing with 0.9% sodium chloride.
• D. Verify the client's identity.

Correct answer: D

Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.

4. A client has a hemoglobin level of 7 g/dL. Which of the following findings should the nurse expect?

• A. Bounding pulses
• B. Elevated blood pressure
• C. Headache
• D. Pale, cool skin

Correct answer: D

Rationale: Pale, cool skin is a common finding in clients with a hemoglobin level of 7 g/dL due to decreased oxygen carrying capacity. Bounding pulses (Choice A) are not typically associated with low hemoglobin levels. Elevated blood pressure (Choice B) is not a common finding in clients with anemia. While headache (Choice C) can occur with anemia, it is not a specific finding directly related to a hemoglobin level of 7 g/dL.

5. A nurse is caring for a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min, and the PR interval is 0.24 seconds. What cardiac rhythm should the nurse interpret this finding as?

• A. First-degree AV block.
• B. Premature ventricular contraction.
• C. Sinus bradycardia.
• D. Atrial fibrillation.

Correct answer: A

Rationale: The correct answer is A: First-degree AV block. A PR interval of 0.24 seconds indicates a prolonged PR interval, which is characteristic of first-degree AV block. This rhythm is considered benign and often does not require treatment. Choice B, premature ventricular contraction, is characterized by early, abnormal ventricular contractions and would not be indicated by the findings provided. Choice C, sinus bradycardia, would present with a normal PR interval but a heart rate less than 60 beats per minute. Choice D, atrial fibrillation, is characterized by an irregularly irregular rhythm with no identifiable P waves, which does not align with the findings of a prolonged PR interval in this scenario.

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