Nursing Elites

1. While preparing a client for a cardiac catheterization, the client expresses a preference to speak with their doctor rather than the nurse. Which response by the nurse should be therapeutic?

• A. Your doctor expects me to prepare you for this procedure.
• B. That's fine, if that's what you want. I'll call your health care provider.
• C. So you're saying that you want to talk to your health care provider?
• D. I'm concerned with the way you've dismissed me. I know what I am doing.

Correct answer: C

Rationale: The therapeutic response by the nurse in this situation involves reflecting the client's feelings back to them, which demonstrates active listening and empathy. By restating the client's preference to talk to their doctor, the nurse acknowledges and validates the client's feelings, thereby fostering a positive therapeutic relationship and promoting open communication. Choices A and B do not acknowledge the client's preference and may come off as dismissive. Choice D is confrontational and defensive, which can lead to a breakdown in communication and trust between the nurse and the client.

2. The client with a history of angina pectoris is being discharged after coronary artery bypass graft (CABG) surgery. Which statement by the client indicates a need for further teaching?

• A. I will avoid lifting heavy objects for at least 6 weeks.
• B. I will call the doctor if I develop a fever or drainage from my incisions.
• C. I will take my pain medication before doing any activities that might cause discomfort.
• D. I can resume my normal activities, including driving, as soon as I feel like it.

Correct answer: D

Rationale: The correct answer is D because after CABG surgery, patients need to follow specific guidelines for resuming activities, and driving is typically restricted for a certain period to ensure safety and proper recovery. Resuming normal activities too soon, including driving, can pose risks to the client's health and safety. It is essential to emphasize to the client the importance of following the healthcare provider's recommendations regarding activity restrictions post-surgery to prevent complications and promote optimal recovery. Choices A, B, and C are correct statements that align with post-CABG discharge instructions, emphasizing the importance of avoiding heavy lifting, monitoring for signs of infection, and managing pain effectively.

3. When preparing to administer medication to a client, what action should the nurse take first?

• A. Verify the client's identity.
• B. Check the medication expiration date.
• C. Review the client's medical history.
• D. Obtain the client's vital signs.

Correct answer: A

Rationale: Verifying the client's identity is the initial and most critical step in medication administration. It is crucial to confirm that the right medication is being given to the correct patient. Checking the client's identity helps prevent medication errors and ensures patient safety. Checking the medication expiration date (choice B) is important but should come after verifying the client's identity. Reviewing the client's medical history (choice C) is valuable but not the first step in medication administration. Obtaining the client's vital signs (choice D) is essential in some situations but is usually not the first action needed before administering medication.

4. The client with a history of angina pectoris reports chest pain unrelieved by nitroglycerin. Which action should the nurse take next?

• A. Administer another dose of nitroglycerin.
• B. Notify the healthcare provider immediately.
• C. Have the client lie down and rest.
• D. Encourage the client to take deep breaths.

Correct answer: B

Rationale: When a client with a history of angina pectoris reports chest pain unrelieved by nitroglycerin, it may indicate a myocardial infarction, also known as a heart attack. In this situation, the nurse should immediately notify the healthcare provider to ensure prompt evaluation and appropriate intervention. Delay in seeking medical attention for chest pain unrelieved by nitroglycerin can be life-threatening, as it might be a sign of a more serious cardiac event. Administering another dose of nitroglycerin (Choice A) without further evaluation can be risky, as the client's condition may require a different intervention. Having the client lie down and rest (Choice C) or encouraging deep breaths (Choice D) are not appropriate actions in this scenario where a more serious cardiac event needs to be ruled out.

5. The client with a diagnosis of heart failure is prescribed spironolactone (Aldactone). Which laboratory value should be monitored closely by the nurse?

• A. Serum calcium
• B. Serum potassium
• C. Serum sodium
• D. Serum glucose

Correct answer: B

Rationale: The correct answer is B: Serum potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring serum potassium levels is crucial to prevent adverse effects associated with high potassium levels, such as cardiac arrhythmias. Monitoring serum calcium (choice A) is not directly related to spironolactone use. Serum sodium (choice C) and serum glucose (choice D) are also not the primary laboratory values to monitor when a client is prescribed spironolactone for heart failure.

Similar Questions