Nursing Elites

1. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?

• A. Decrease venous congestion.
• B. Maintain normal respirations.
• C. Maintain body temperature.
• D. Prevent injury to lower extremities.

Correct answer: A

Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.

2. The client with chronic renal failure is receiving education on managing fluid intake. Which of the following statements by the client indicates a need for further teaching?

• A. I can drink as much water as I want.
• B. I should increase my intake of high-sodium foods.
• C. I can skip a dialysis session if I feel tired.
• D. I can eat whatever I want as long as I take my medications.

Correct answer: C

Rationale: Choice C is the correct answer. Clients with chronic renal failure should not skip dialysis sessions, as this can lead to serious complications. Dialysis is crucial for managing fluid and electrolyte balance in these clients. Choice A is incorrect because clients with renal failure often have fluid restrictions. Choice B is incorrect as high-sodium foods can worsen fluid retention in clients with renal failure. Choice D is incorrect because dietary restrictions are important in managing chronic renal failure, and eating whatever one wants can lead to further complications.

3. The nurse is caring for a patient who is receiving furosemide (Lasix) and an aminoglycoside antibiotic. The nurse will be most concerned if the patient reports which symptom?

• A. Dizziness
• B. Dysuria
• C. Nausea
• D. Tinnitus

Correct answer: D

Rationale: The correct answer is D: Tinnitus. When furosemide and an aminoglycoside antibiotic are used together, there is an increased risk of ototoxicity. Tinnitus, a ringing in the ears, is a common early sign of ototoxicity. Dizziness (choice A) is a common side effect of furosemide but not specifically related to this drug interaction. Dysuria (choice B) is painful urination and is not directly associated with this drug combination. Nausea (choice C) is a common side effect of furosemide but is not specifically indicative of ototoxicity caused by the drug interaction.

4. A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned?

• A. Oxygen saturation of 97%
• B. Equal breath sounds in both lungs
• C. Absence of cough and gag reflexes
• D. Respiratory rate of 20 breaths/min

Correct answer: C

Rationale: The correct answer is C. The absence of cough and gag reflexes is the most concerning finding for the nurse because it indicates a lack of protective airway reflexes, putting the client at risk of aspiration. Oxygen saturation of 97% is within the normal range and indicates adequate oxygenation. Equal breath sounds in both lungs are a positive finding, indicating no significant abnormalities. A respiratory rate of 20 breaths/min is also within the normal range and does not raise immediate concerns. Therefore, the absence of cough and gag reflexes poses the highest risk to the client's airway safety.

5. In a patient with type 1 diabetes, which of the following is a sign of diabetic ketoacidosis (DKA)?

• A. Polyuria
• B. Bradycardia
• C. Dry skin
• D. Tachycardia

Correct answer: D

Rationale: Tachycardia is a sign of diabetic ketoacidosis (DKA) in a patient with type 1 diabetes. In DKA, the body responds to hyperglycemia and dehydration by increasing heart rate. Polyuria (increased urination) is a symptom of diabetes but not specific to DKA. Bradycardia (slow heart rate) and dry skin are not typical signs of DKA; instead, tachycardia and other signs of volume depletion are more common.

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