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. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper, and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

• A. Establish a toileting schedule to decrease episodes of incontinence
• B. Complete a functional assessment of the client’s self-care abilities
• C. Apply a barrier ointment to intact areas that may be exposed to moisture
• D. Determine the size and depth of skin breakdown over the sacral area

Correct answer: D

Rationale: The initial step the nurse should take when faced with skin breakdown over the sacral area of the client is to determine the size and depth of the affected area. Assessing and documenting these aspects are crucial before initiating any treatment. This evaluation will guide the nurse in developing an appropriate care plan to address the skin breakdown effectively. Options A, B, and C are not the first steps to take in this situation. While establishing a toileting schedule and completing a functional assessment are important, assessing the size and depth of the skin breakdown is the priority to initiate proper treatment. Applying a barrier ointment without assessing the extent of the breakdown may not address the underlying issue effectively.

3. When caring for a client in hemorrhagic shock, how should the nurse position the client?

• A. Flat in bed with legs elevated.
• B. Flat in bed.
• C. Trendelenburg position.
• D. Semi-Fowler's position.

Correct answer: A

Rationale: When caring for a client in hemorrhagic shock, the nurse should position the client flat in bed with legs elevated. Elevating the legs helps increase venous return to the heart, aiding in the management of hemorrhagic shock by maintaining perfusion to vital organs.

4. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take?

• A. Record the coughing incident. No further action is required at this time.
• B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
• C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
• D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Correct answer: C

Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small-bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes. The nurse should assess tube placement in this way before taking any other action to ensure the tube is still in the correct position and prevent potential complications. Choice A is incorrect because further assessment is needed due to the risk of tube displacement. Choice B is incorrect as stopping the feeding and involving the family is premature without confirming tube placement. Choice D is incorrect as injecting air and auscultating for gurgling is not the recommended method to confirm tube placement.

5. The healthcare professional counts an adult's apical heartbeat at 110 beats per minute. The healthcare professional describes this as:

• A. Asystole
• B. Bigeminy
• C. Tachycardia
• D. Bradycardia

Correct answer: C

Rationale: Tachycardia is a heart rate greater than 100 beats per minute. In this case, an adult's heart rate of 110 beats per minute falls within the range of tachycardia. Tachycardia can be a common physiological response to various stresses on the body, leading to an increased heart rate. Asystole refers to the absence of cardiac activity, bigeminy is a specific heart rhythm pattern, and bradycardia is a heart rate below 60 beats per minute in adults.

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