Nursing Elites

1. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?

• A. Chest pain
• B. Pallor
• C. Inspiratory crackles
• D. Heart murmur

Correct answer: C

Rationale: Inspiratory crackles are a common finding in patients with congestive heart failure due to the accumulation of fluid in the lungs, leading to crackling sounds during inspiration. Chest pain (Choice A) is more commonly associated with conditions like angina or myocardial infarction and is not a typical symptom of congestive heart failure. Pallor (Choice B) is a general symptom of various conditions and not specific to congestive heart failure. While a heart murmur (Choice D) may be heard in some cases of congestive heart failure, it is not as consistent as inspiratory crackles in indicating the condition.

2. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing?

• A. Serum albumin 3 g/dL
• B. Total lymphocyte count 2400/mm3
• C. HCT 42%
• D. HGB 16 g/dL

Correct answer: A

Rationale: The correct answer is A: Serum albumin 3 g/dL. Low levels of serum albumin indicate poor nutritional status and can impair wound healing. Total lymphocyte count, HCT, and HGB levels are not directly related to wound healing and do not pose a significant risk for poor wound healing in this context. Total lymphocyte count reflects the immune status, HCT measures the percentage of red blood cells in blood, and HGB measures the amount of hemoglobin in blood.

3. During a neurologic examination, which assessment should a nurse perform to test a client's balance?

• A. Romberg test
• B. Heel-to-toe walk
• C. Snellen test
• D. Spinal accessory function

Correct answer: A

Rationale: The Romberg test is used to assess a client's balance by evaluating their ability to maintain a steady posture with eyes closed. The heel-to-toe walk is another assessment that tests balance by assessing gait and coordination. The Snellen test is used to assess visual acuity and is unrelated to balance. Testing spinal accessory function involves assessing the movement of the head and shoulders and is not directly related to balance assessment.

4. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

• A. Use gentle suction to prevent tissue damage.
• B. Instruct the patient to blow their nose forcefully to clear the passage.
• C. Place a dry washcloth under the nose to absorb secretions.
• D. Insert a cotton-tipped applicator into the back of the nose.

Correct answer: A

Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (Choice B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (Choice C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (Choice D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.

5. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?

• A. Administer a bronchodilator
• B. Obtain a peak flow reading
• C. Provide supplemental oxygen
• D. Assess the client's respiratory rate

Correct answer: A

Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.

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