Nursing Elites

1. A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?

• A. Presence of ascites
• B. Bilateral lung crackles
• C. Jugular vein distention
• D. Pedal edema bilaterally

Correct answer: B

Rationale: When assessing a client with a history of left-sided heart failure, the presence of bilateral lung crackles is a key finding to determine if the condition is currently active. Crackles in the lungs indicate fluid accumulation, a common sign of left-sided heart failure due to pulmonary congestion. Choices A, C, and D are incorrect because ascites, jugular vein distention, and pedal edema are more commonly associated with right-sided heart failure.

2. The client with myocardial infarction should reduce intake of saturated fat and cholesterol. Which food items from the dietary menu would assist the nurse in helping the client comply with diet therapy?

• A. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet
• B. Pork chop, baked potato, cauliflower in cheese sauce, ice cream
• C. Baked haddock, steamed broccoli, herbed rice, sliced strawberries
• D. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

Correct answer: C

Rationale: Option C, which includes baked haddock, steamed broccoli, herbed rice, and sliced strawberries, is the most appropriate choice for a client with myocardial infarction looking to reduce saturated fat and cholesterol intake. This meal is low in saturated fats and cholesterol, making it a heart-healthy option that aligns with the dietary recommendations for such clients. Choices A, B, and D contain foods high in saturated fats and cholesterol, which are not suitable for a client with myocardial infarction trying to adhere to a diet therapy aimed at reducing these components.

3. The healthcare professional is assessing a client who presents with jaundice. Which assessment finding is most important for the healthcare professional to follow up on?

• A. Urine specific gravity of 1.03
• B. Frothy, tea-colored urine
• C. Clay-colored stools
• D. Elevated serum amylase and lipase levels

Correct answer: D

Rationale: Elevated serum amylase and lipase levels are indicative of pancreatitis, a serious condition that can manifest with jaundice. Timely follow-up is crucial to manage pancreatitis and its complications effectively in a jaundiced client. Choices A, B, and C are less critical in this scenario. Urine specific gravity within normal range, frothy tea-colored urine, and clay-colored stools can be associated with various conditions but are not directly indicative of pancreatitis, which is the most concerning condition associated with jaundice.

4. A nurse is assessing a client who is taking amiodarone. Which of the following findings should the nurse report to the provider?

• A. Dry skin
• B. Weight loss
• C. Bradycardia
• D. Productive cough

Correct answer: D

Rationale: A productive cough can indicate pulmonary toxicity, a serious side effect of amiodarone, and should be reported. Dry skin is not typically associated with amiodarone use. Weight loss is a common side effect of amiodarone but not generally a cause for concern unless severe. Bradycardia is a known side effect of amiodarone and may not necessarily require immediate reporting unless symptomatic.

5. A client with peptic ulcer disease is being taught about managing the disorder. Which of the following statements by the client indicates an understanding of the teaching?

• A. 'I should take NSAIDs for pain relief.'
• B. 'I should avoid drinking alcohol.'
• C. 'I should eat small, frequent meals.'
• D. 'I should drink milk to coat my stomach.'

Correct answer: B

Rationale: The correct answer is B. Avoiding alcohol is crucial in managing peptic ulcer disease as it helps prevent irritation and further damage to the stomach lining. Alcohol can worsen symptoms and hinder the healing process in individuals with this condition. Choice A is incorrect because NSAIDs can worsen peptic ulcers by irritating the stomach lining. Choice C is a correct dietary recommendation for managing peptic ulcer disease as it helps reduce stomach acid secretion and promotes healing. Choice D is incorrect as milk may temporarily soothe ulcer pain, but it can stimulate acid production and worsen symptoms in the long run.

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