Nursing Elites

1. A client with heart failure is prescribed furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 100/60 mmHg
• C. Crackles in the lungs
• D. Presence of a new murmur

Correct answer: C

Rationale: The correct answer is C. Crackles in the lungs indicate fluid overload, a common issue in heart failure patients. Immediate intervention is necessary to prevent worsening heart failure symptoms and potential complications. A heart rate of 60 beats per minute and a blood pressure of 100/60 mmHg are within normal ranges for many individuals and do not typically require immediate intervention in this context. The presence of a new murmur may be important to monitor but is not the priority when crackles in the lungs suggest fluid overload.

2. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take?

• A. Administer the Toprol immediately and monitor the client until the heart rate increases.
• B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP q30 minutes.
• C. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180.
• D. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.

Correct answer: D

Rationale: In clients with second-degree heart block, beta blockers such as metoprolol (Toprol SR) are contraindicated as they can further decrease the heart rate. Administering metoprolol in this situation can lead to serious complications. The correct action for the nurse to take is to hold the scheduled dose of Toprol and promptly notify the healthcare provider of the telemetry pattern. This ensures patient safety and appropriate management of the cardiac condition. Choices A, B, and C are incorrect because administering Toprol despite the heart block can worsen the condition and pose a risk to the client's health.

3. A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mother enters the labor suite and says in a loud voice, 'I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!' What action should the nurse take?

• A. Tell the mother to stop speaking for the client.
• B. Notify the charge nurse of the situation.
• C. Request that the mother leave the room.
• D. Request security to remove her from the room.

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to request that the mother leave the room. This is important to maintain a calm environment and allow the healthcare team to assess and manage the situation without interference. Option A is not the best choice as it may escalate the situation. Option B, notifying the charge nurse, could be considered after addressing the immediate need to remove the mother from the room. Option D, requesting security to remove her, is not necessary at this point and may further escalate the situation unnecessarily.

4. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

• A. Expresses an understanding of the procedure.
• B. NPO for 6 hrs.
• C. No known drug allergies.
• D. Intravenous access intact.

Correct answer: A

Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.

5. The nurse is assessing a client with left-sided heart failure. Which finding should be reported to the healthcare provider immediately?

• A. Shortness of breath
• B. Jugular venous distention
• C. Crackles in the lungs
• D. Elevated liver enzymes

Correct answer: C

Rationale: In a client with left-sided heart failure, the presence of crackles in the lungs is the most critical finding that should be reported to the healthcare provider immediately. Crackles indicate pulmonary congestion, which requires prompt intervention to prevent respiratory compromise. Shortness of breath, though a common symptom in heart failure, is a result of pulmonary congestion, making crackles a more direct indicator of the severity of the condition. Jugular venous distention and elevated liver enzymes are important to assess in heart failure but are not as immediately concerning as crackles in the lungs, which directly reflect the impact of heart failure on the respiratory system.

Similar Questions