Nursing Elites

1. A client with a history of heart failure is admitted with pulmonary edema. Which finding requires immediate intervention?

• A. Peripheral edema.
• B. Oxygen saturation of 88%.
• C. Jugular vein distention.
• D. Productive cough with pink, frothy sputum.

Correct answer: D

Rationale: A productive cough with pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. This finding requires immediate intervention to prevent respiratory compromise and worsening of the condition. Peripheral edema (Choice A) is a manifestation of heart failure but is not as urgent as addressing pulmonary edema. Oxygen saturation of 88% (Choice B) is low and requires attention, but the pink, frothy sputum signifies acute respiratory distress. Jugular vein distention (Choice C) can be seen in heart failure, but the immediate concern in this scenario is addressing the pulmonary edema to ensure adequate gas exchange and oxygenation.

2. The nurse is caring for a client with a nasogastric tube to continuous suction. Which electrolyte imbalance should the nurse monitor for?

• A. Hypercalcemia.
• B. Hypokalemia.
• C. Hyponatremia.
• D. Hypomagnesemia.

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. When a client has a nasogastric tube to continuous suction, potassium loss through gastric fluids can lead to hypokalemia. Hypercalcemia (Choice A) is not typically associated with continuous suction. Hyponatremia (Choice C) involves sodium imbalance and is not directly related to nasogastric suction. Hypomagnesemia (Choice D) is not the primary concern in this situation, as potassium loss is more significant with gastric suction.

3. The healthcare provider is assessing a client with a suspected pulmonary embolism. Which finding requires immediate intervention?

• A. Chest pain.
• B. Shortness of breath.
• C. Tachycardia.
• D. Cyanosis.

Correct answer: D

Rationale: Cyanosis is a late sign of hypoxemia and indicates severe oxygen deprivation, necessitating immediate intervention in a client with a suspected pulmonary embolism. Chest pain, shortness of breath, and tachycardia are also concerning symptoms in pulmonary embolism; however, cyanosis signifies critical oxygen deficiency and warrants urgent attention to prevent further complications.

4. The nurse is preparing to administer an oral medication to a client with dysphagia. Which action should the nurse take?

• A. Crush the medication and mix it with applesauce.
• B. Have the client drink a full glass of water with the medication.
• C. Administer the medication with a small amount of pudding.
• D. Place the medication at the back of the client's tongue.

Correct answer: C

Rationale: The correct action for the nurse to take when administering oral medication to a client with dysphagia is to administer the medication with a small amount of pudding. This method helps prevent aspiration in clients with dysphagia by ensuring easier swallowing. Crushing the medication and mixing it with applesauce (Choice A) might alter the medication's efficacy. Having the client drink a full glass of water with the medication (Choice B) may not be suitable for a client with dysphagia as it can increase the risk of aspiration. Placing the medication at the back of the client's tongue (Choice D) can also lead to aspiration and is not recommended.

5. When planning a scoliosis screening clinic, which age group should be included?

• A. early adolescent girls
• B. late adolescent boys
• C. 7-10 year old boys
• D. preschoolers of both genders

Correct answer: A

Rationale: The correct answer is early adolescent girls. Scoliosis is most commonly diagnosed during early adolescence, with girls being more affected than boys. Including early adolescent girls in the screening clinic aligns with the age group that is at higher risk for scoliosis. Late adolescent boys (choice B) are less likely to develop scoliosis compared to early adolescent girls. 7-10 year old boys (choice C) are typically younger than the age group where scoliosis is commonly diagnosed. Preschoolers of both genders (choice D) are too young for scoliosis screening as the condition usually manifests during adolescence.

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