Nursing Elites

1. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Chest X-ray
• B. Arterial blood gases (ABGs)
• C. Echocardiogram
• D. Electrocardiogram (ECG)

Correct answer: C

Rationale: The correct answer is C: Echocardiogram. An echocardiogram should be performed first to assess ventricular function and evaluate the cause of shortness of breath and crackles in a client with heart failure. An echocardiogram provides valuable information about the heart's structure and function, helping to identify potential issues related to heart failure. Chest X-ray (Choice A) may be done to assess for changes in heart size or fluid in the lungs but does not directly assess heart function. Arterial blood gases (Choice B) may provide information about oxygenation but do not directly evaluate heart function. An electrocardiogram (Choice D) assesses the heart's electrical activity but does not provide detailed information about ventricular function, which is crucial in heart failure management.

2. A female client reports that her hair is becoming coarse and breaking off, the outer part of her eyebrows has disappeared, and her eyes are all puffy. Which follow-up question is best for the nurse to ask?

• A. Is there a history of female baldness in your family?
• B. Are you under any unusual stress at home or work?
• C. Do you work with hazardous chemicals?
• D. Have you noticed any changes in your fingernails?

Correct answer: D

Rationale: The correct answer is D because the manifestations reported by the client, such as coarse hair, missing eyebrows, and puffy eyes, are indicative of hypothyroidism. Changes in the fingernails, such as brittle or pitted nails, can also be associated with hypothyroidism. Option A is incorrect as female baldness is not directly related to the reported symptoms. Option B is less relevant as stress typically does not cause these specific symptoms. Option C is also less relevant as exposure to hazardous chemicals would present with different symptoms.

3. The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?

• A. Supine with the head elevated 30 degrees
• B. Left lateral with the right leg flexed
• C. Sims’ position with the right leg flexed
• D. Prone position with the head turned to the side

Correct answer: C

Rationale: Sims’ position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.

4. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

• A. Cleanse the foot with soap and water and apply an antibiotic ointment
• B. Provide teaching about the need for a tetanus booster within the next 72 hours.
• C. Have the mother check the child's temperature every 4 hours for the next 24 hours
• D. Transfer the child to the emergency department to receive a gamma globulin injection

Correct answer: A

Rationale: The correct first action for the nurse to implement is to cleanse the foot with soap and water and apply an antibiotic ointment to prevent infection. In cases of puncture wounds like stepping on a rusty nail, the immediate concern is to reduce the risk of infection. Providing teaching about the need for a tetanus booster within the next 72 hours is important as well, but it should come after the wound is cleansed. Checking the child's temperature and transferring to the emergency department for a gamma globulin injection are not the immediate priorities in this scenario.

5. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?

• A. I am having pain in my lower back when I move my legs
• B. My throat hurts when I swallow
• C. I feel sick to my stomach and am going to throw up
• D. I have a headache that gets worse when I sit up

Correct answer: D

Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.

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