Nursing Elites

1. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

• A. Heart rate of 122 bpm and respiratory rate of 28.
• B. Yellow sputum expectorated.
• C. Temperature of 100.5°F (38.1°C).
• D. Shortness of breath on exertion.

Correct answer: C

Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.

2. A client is receiving a blood transfusion and develops a fever. What is the nurse's first action?

• A. Administer an antipyretic as prescribed.
• B. Stop the transfusion and notify the healthcare provider.
• C. Slow the rate of the transfusion.
• D. Continue the transfusion and reassess in 15 minutes.

Correct answer: B

Rationale: The correct first action when a client receiving a blood transfusion develops a fever is to stop the transfusion and notify the healthcare provider. This is crucial to prevent further reactions and ensure prompt intervention. Administering an antipyretic (Choice A) may mask symptoms and delay appropriate treatment. Slowing the rate of the transfusion (Choice C) might not address the underlying cause of the fever. Continuing the transfusion and reassessing in 15 minutes (Choice D) could worsen the client's condition if there is a severe reaction occurring.

3. A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give sugar water only.
• B. Offer the infant oral rehydration every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

4. What is the expected outcome of prescribing a proton pump inhibitor to a client with a peptic ulcer?

• A. Promote healing of the gastric mucosa.
• B. Neutralize the effects of stomach acid.
• C. Inhibit the growth of Helicobacter pylori.
• D. Reduce gastric acid secretion.

Correct answer: D

Rationale: The correct answer is D: Reduce gastric acid secretion. Proton pump inhibitors (PPIs) work by reducing gastric acid secretion, which helps prevent further irritation of the gastric mucosa and allows ulcers to heal. While promoting healing of the gastric mucosa (Choice A) is an indirect outcome of reducing gastric acid secretion, the primary mechanism of PPIs is to lower acid levels. Choice B, neutralizing the effects of stomach acid, is typically associated with antacids, not PPIs. Inhibiting the growth of Helicobacter pylori (Choice C) is usually achieved with antibiotics, not PPIs.

5. What safety measure should the nurse take for a client with a seizure disorder who has an IV line?

• A. Ensure that the IV site is padded and protected.
• B. Limit the client's mobility to prevent dislodging the IV.
• C. Place the IV site on the same side as the seizure activity.
• D. Ensure the client is positioned on the opposite side of the IV line.

Correct answer: D

Rationale: The correct answer is D: Ensure the client is positioned on the opposite side of the IV line. Placing the IV line on the opposite side of any seizure activity is essential to prevent injury. It helps to ensure that the IV line is not dislodged during a seizure. Choices A, B, and C are incorrect. While padding and protecting the IV site is important, the priority is to position the client on the side opposite to the IV line to prevent dislodgement and injury during a seizure.

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