Nursing Elites

1. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

• A. Increased blood pressure
• B. Increased heart rate
• C. Loss of pulse in the extremity
• D. Decreased urine output

Correct answer: C

Rationale: Loss of pulse in the extremity can indicate an arterial blockage, requiring immediate medical evaluation. Increased blood pressure and heart rate are common physiological responses after cardiac catheterization and may not necessarily indicate a complication. Decreased urine output is more indicative of renal function and may not be directly related to complications from the procedure.

2. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

• A. drowsiness
• B. complaint of nausea
• C. pulse rate of 92
• D. restlessness

Correct answer: D

Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.

3. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A. FHT 168 beats/min
• B. Temperature 100 degrees Fahrenheit
• C. Cervical dilation of 4 cm
• D. BP 138/88

Correct answer: A

Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.

4. A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements by the nurse is appropriate?

• A. Use sugar-free gum if you experience a metallic taste in your mouth.
• B. Drink fluids at mealtime to prevent early satiety.
• C. Foods that are higher in fat can help nausea.
• D. Raw fruits and vegetables will be easier for your body to digest.

Correct answer: A

Rationale: The correct answer is A. Using sugar-free gum can help alleviate the metallic taste often experienced during chemotherapy treatments. Choices B, C, and D are incorrect. Drinking fluids at mealtime may worsen early satiety, foods higher in fat can exacerbate nausea, and raw fruits and vegetables may be harder for the body to digest and may pose a risk of infection for individuals with compromised immune systems.

5. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

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