Nursing Elites

1. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding is most consistent with this diagnosis?

• A. Dependent edema.
• B. Ascites.
• C. Nocturia.
• D. Orthopnea.

Correct answer: D

Rationale: Orthopnea (D) is most consistent with left-sided heart failure. It is characterized by difficulty breathing when lying flat and is relieved by sitting up or standing. Dependent edema (A), ascites (B), and nocturia (C) are more commonly associated with right-sided heart failure. Dependent edema refers to swelling due to fluid accumulation, ascites is the accumulation of fluid in the peritoneal cavity, and nocturia is the excessive need to urinate during the night, all of which are more indicative of right-sided heart failure.

2. After abdominal surgery, an adult is now alert and oriented. What position is most appropriate for the client?

• A. Semi-Fowler's
• B. Prone
• C. Supine
• D. Sim's

Correct answer: A

Rationale: The most appropriate position for a client following abdominal surgery is Semi-Fowler's. This position promotes greater thoracic expansion and reduces pressure on the suture line, aiding in respiratory function and preventing strain on the incision site. Choices B, C, and D are incorrect. Prone position (Choice B) would not be suitable after abdominal surgery as it can put pressure on the abdomen. Supine position (Choice C) may cause discomfort and strain on the incision area. Sim's position (Choice D) is primarily used for rectal exams and enemas, which are unrelated to the needs post-abdominal surgery.

3. Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?

• A. Shaving the neck.
• B. Establishing a means of communication.
• C. Inserting a Foley catheter.
• D. Starting an IV.

Correct answer: B

Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.

4. The census on the unit is 90 percent, and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?

• A. A double room with a client admitted for impetigo.
• B. A double room with another client with the same diagnosis.
• C. A four-bed room with three clients who have had orthopedic surgery.
• D. A double room with an elderly client with a diagnosis of chickenpox.

Correct answer: B

Rationale: When a private room is not an option, the best choice is to assign the elderly client with influenza to a double room with another client diagnosed with the same condition. This is ideal as droplet precautions would likely already be in place for the other client, reducing the risk of spreading the infection to other clients in the unit. Choice A is not appropriate as impetigo does not require the same precautions as influenza. Choice C is not ideal as orthopedic surgery does not involve respiratory precautions. Choice D is incorrect because chickenpox requires airborne precautions, which could pose a risk to the elderly client with influenza.

5. The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?

• A. Notify the surgical team of the client’s confusion
• B. Have the client sign a new surgical consent
• C. Add the correct leg information to the consent form
• D. Inform the surgeon about the client’s concern

Correct answer: D

Rationale: In this scenario, the nurse should inform the surgeon about the client’s concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.

Similar Questions