Nursing Elites

1. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

• A. Weight gain of 2 pounds in 24 hours
• B. Presence of a cough
• C. Edema in the lower extremities
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.

2. The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?

• A. Assess the client's oxygen saturation level
• B. Teach the client pursed-lip breathing techniques
• C. Determine the client's history of lung disease
• D. Obtain an arterial blood gas sample

Correct answer: A

Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.

3. The nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

• A. Monitor the client's respiratory status
• B. Teach the client how to use the PCA pump
• C. Evaluate the client's pain level
• D. Assess the client's pain level

Correct answer: A

Rationale: The correct answer is to monitor the client's respiratory status. When administering opioids like morphine sulfate via a PCA pump, it is crucial to closely monitor the client's respiratory status to detect signs of respiratory depression early. This is important for ensuring the client's safety while receiving pain management. Choices B, C, and D are incorrect because while teaching the client to use the PCA pump and assessing or evaluating their pain level are essential aspects of care, monitoring respiratory status takes precedence due to the potential risks associated with opioid use.

4. A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2°F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

• A. Occult blood in the stool
• B. Abdominal distention
• C. Elevated urine specific gravity
• D. Hyperactive bowel sounds

Correct answer: C

Rationale: Elevated urine specific gravity is a sign of dehydration in children. In the scenario provided, the child is experiencing increased stool frequency, liquid consistency, fever, and vomiting, indicating fluid loss and potential dehydration. Occult blood in the stool may suggest gastrointestinal bleeding but is not a direct indicator of dehydration. Abdominal distention can be seen in various conditions and is not specific to dehydration. Hyperactive bowel sounds are more commonly associated with increased bowel motility, not necessarily dehydration.

5. A nurse is planning care for a client who has a new prescription for metoprolol (Lopressor). Which assessment finding should the nurse report to the healthcare provider before administering the medication?

• A. Heart rate of 50 beats per minute
• B. Blood pressure of 90/60 mm Hg
• C. Respiratory rate of 20 breaths per minute
• D. Temperature of 99°F (37.2°C)

Correct answer: A

Rationale: A heart rate of 50 beats per minute is a concerning finding that should be reported before administering metoprolol. Metoprolol is a beta-blocker that can further lower the heart rate, so a heart rate of 50 bpm indicates potential bradycardia, which is a contraindication for administering this medication. Choices B, C, and D are within normal ranges and do not pose immediate concerns related to metoprolol administration.

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