Nursing Elites

1. A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?

• A. Jugular vein distention.
• B. Crackles in the lungs.
• C. Peripheral edema.
• D. Hepatomegaly.

Correct answer: C

Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.

2. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

• A. Maintain the client in a lateral position using protective wrist and vest restraints.
• B. Position the client prone with a small pillow below the diaphragm.
• C. Raise the head and knee gatch when lying in a supine position.
• D. Transfer the client to a wheelchair close to the nursing station for observation.

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

3. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

• A. Make the client comfortable and allow the client to sleep.
• B. Assess the client's neurologic status.
• C. Notify the surgeon about the comment.
• D. Ask the client's family to co-sign the operative permit.

Correct answer: B

Rationale: The nurse should assess the client's neurologic status next. The client's statement about aliens and subsequent falling asleep could be indicative of a potential neurological issue such as confusion or altered mental status. It is essential to assess the client's neurological status to determine the underlying cause of the client's statement and behavior. This assessment will help the nurse identify any potential cognitive impairment or neurological deficits that may need immediate attention, ensuring the client's safety and well-being. Notifying the surgeon or involving the client's family can be considered later, but the priority is to assess the client's neurologic status to address any immediate concerns.

4. When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client’s laboratory values for potassium levels will help confirm the presence of hypokalemia.

5. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse.
• B. Encourage the client to get to the toilet.
• C. In a loud voice, call for help.
• D. Gently lower the client to the floor.

Correct answer: D

Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.

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