Nursing Elites

1. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

• A. Take the medication before bedtime.
• B. Report any weight gain of more than 2 pounds in a day.
• C. Increase your intake of high-sodium foods.
• D. Limit your fluid intake to less than 1 liter per day.

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

2. The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?

• A. Continuous bubbling in the water seal chamber.
• B. Serosanguineous drainage in the collection chamber.
• C. Intermittent bubbling in the suction control chamber.
• D. Chest tube secured to the client's chest wall.

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which requires immediate intervention to prevent complications such as pneumothorax. An air leak can lead to ineffective lung expansion, respiratory distress, and compromised gas exchange. Therefore, prompt action is necessary to maintain the integrity of the closed drainage system and prevent further complications. Choices B, C, and D are incorrect because serosanguineous drainage is an expected finding post-thoracotomy, intermittent bubbling in the suction control chamber is normal, and having the chest tube secured to the client's chest wall is essential for stability and proper functioning.

3. When assessing a client reporting severe pain in the right lower quadrant of the abdomen, which sign would most likely indicate appendicitis?

• A. Rebound tenderness at McBurney's point.
• B. Positive Murphy's sign.
• C. Rovsing's sign.
• D. Cullen's sign.

Correct answer: A

Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This sign indicates peritoneal irritation, a common feature of appendicitis. McBurney's point is located in the right lower quadrant of the abdomen and is a focal point for assessing tenderness. Positive Murphy's sign is associated with cholecystitis, not appendicitis. Rovsing's sign is elicited by palpation of the left lower quadrant resulting in pain in the right lower quadrant, also suggestive of appendicitis. Cullen's sign is associated with acute pancreatitis and manifests as periumbilical ecchymosis.

4. Prior to elective surgery, a patient taking warfarin should receive which instruction regarding warfarin therapy?

• A. Continue taking warfarin until the day of surgery.
• B. Stop taking warfarin three days before surgery.
• C. Switch to aspirin before surgery.
• D. Stop taking warfarin one week before surgery.

Correct answer: D

Rationale: Prior to elective surgery, a patient taking warfarin should be instructed to stop taking warfarin around one week before the procedure. This timeframe allows for the effects of warfarin to diminish, lowering the risk of excessive bleeding during surgery. Continuing warfarin until the day of surgery (Choice A) increases the risk of bleeding complications. Stopping warfarin three days before surgery (Choice B) may not provide enough time for the anticoagulant effects to subside. Switching to aspirin before surgery (Choice C) is not recommended as a substitute for warfarin in this context.

5. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What intervention can the nurse expect the healthcare provider to prescribe?

• A. Nitrofurantoin (Macrodantin) orally.
• B. Erythropoietin (Epogen) intravenously.
• C. Kayexalate retention enema.
• D. Azathioprine (Imuran) orally.

Correct answer: C

Rationale: In acute renal failure with high serum potassium levels, the healthcare provider is likely to prescribe a Kayexalate retention enema. Kayexalate is a medication used to lower elevated potassium levels by promoting potassium excretion through the gastrointestinal tract, thus aiding in the management of hyperkalemia in clients with renal failure.

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