Nursing Elites

1. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client’s admitting diagnosis?

• A. Jugular vein distention.
• B. Crackles in the lung bases.
• C. Peripheral edema.
• D. Bounding peripheral pulses.

Correct answer: B

Rationale: The correct answer is B: Crackles in the lung bases. Crackles in the lung bases are indicative of pulmonary congestion, which is a classic sign of left-sided heart failure. Left-sided heart failure leads to a backup of blood into the lungs, causing fluid leakage into the alveoli and resulting in crackles upon auscultation. Choices A, C, and D are less specific to left-sided heart failure. Jugular vein distention can be seen in right-sided heart failure, peripheral edema can be seen in both right and left-sided heart failure, and bounding peripheral pulses are more indicative of conditions like hyperthyroidism or anemia rather than specifically supporting left-sided heart failure.

2. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?

• A. Two liters.
• B. Three liters.
• C. Four liters.
• D. Five liters.

Correct answer: B

Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.

3. The nurse is reviewing blood pressure readings for a group of clients on a medical unit. Which client is at the highest risk for complications related to hypertension?

• A. Post-menopausal Caucasian female who overeats and is 20% above her ideal body weight.
• B. Young adult Hispanic female who has hemoglobin at 11 g/dl (110 g/L) and drinks beer daily.
• C. Older adult who consumes a diet of smoked, cured, and pickled foods.
• D. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL (256.4 micromol/L).

Correct answer: D

Rationale: The correct answer is D. An elevated serum creatinine level indicates kidney damage, which significantly increases the risk of complications from hypertension. High blood pressure can damage the kidneys over time, leading to impaired kidney function. Choices A, B, and C do not directly correlate with increased risk of complications related to hypertension. Choice A focuses on obesity and overeating, Choice B on anemia and alcohol consumption, and Choice C on a diet high in sodium and nitrates, none of which are as directly related to hypertension complications as kidney damage.

4. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?

• A. Apply a cool compress to the affected fingers for 20 minutes
• B. Secure a pulse oximeter to monitor the client's oxygen saturation
• C. Report the finding to the healthcare provider as soon as possible
• D. Continue to monitor the fingers until the color returns to normal

Correct answer: D

Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.

5. A client with cirrhosis is receiving lactulose. What is the desired effect of this medication?

• A. Decrease blood glucose levels
• B. Reduce serum ammonia levels
• C. Increase platelet count
• D. Lower serum bilirubin levels

Correct answer: B

Rationale: The correct answer is B: Reduce serum ammonia levels. Lactulose is used to reduce serum ammonia levels in clients with cirrhosis, helping to prevent hepatic encephalopathy. Lactulose works by acidifying the colon, trapping ammonia for excretion. Decreasing blood glucose levels (choice A) is not the primary effect of lactulose. Increasing platelet count (choice C) and lowering serum bilirubin levels (choice D) are not direct effects of lactulose in the management of cirrhosis.

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