Nursing Elites

1. A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Apical pulse of 58 beats per minute
• C. Presence of a new murmur
• D. Blood pressure of 100/60 mmHg

Correct answer: C

Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.

2. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products while in the operating room. His current blood pressure is 78/52 mm Hg, he is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values include hemoglobin 7.0 g/dL, platelets 20,000/mm³, and white blood cells 1,500/mm³. Based on these assessment findings, which intervention should the nurse implement first?

• A. Transfuse packed red blood cells.
• B. Obtain blood and sputum cultures.
• C. Infuse 1000 ml of normal saline.
• D. Titrate oxygen to keep O2 saturation at 90%.

Correct answer: A

Rationale: The client is exhibiting signs of severe anemia and hypovolemic shock, indicated by low hemoglobin levels and hypotension. The first priority is to address the low hemoglobin by transfusing packed red blood cells to improve oxygen-carrying capacity and perfusion to vital organs. While obtaining blood and sputum cultures is important for identifying potential infections, infusing normal saline can help with volume expansion but does not address the primary issue of severe anemia. Titrating oxygen to maintain an oxygen saturation of 90% is crucial but should follow the administration of packed red blood cells to optimize oxygen delivery.

3. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?

• A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
• B. A client with a healing surgical wound
• C. A client requiring wound dressing change
• D. A client with stable vital signs needing medication administration

Correct answer: A

Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.

4. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?

• A. Advise the UAP to resume positioning the client on schedule
• B. Notify the healthcare provider
• C. Document the UAP's actions
• D. Discuss the situation with the client’s family

Correct answer: A

Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.

5. A 59-year-old male client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?

• A. Malignancy
• B. Infection
• C. Benign cyst
• D. Lymphadenitis

Correct answer: A

Rationale: The correct answer is A: Malignancy. A large, non-tender, hardened lymph node is a typical sign of malignancy and warrants further investigation. Choice B (Infection) is incorrect because typically in infections, lymph nodes are tender and may show signs of inflammation. Choice C (Benign cyst) is incorrect as a benign cyst would usually present as a soft, mobile lump. Choice D (Lymphadenitis) is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes due to inflammation.

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