Nursing Elites

1. A client with heart failure who is on a low sodium diet reports a weight gain of 2 kg in 24 hours. Which intervention should the nurse implement first?

• A. Instruct the client to reduce fluid intake
• B. Monitor the client's intake and output
• C. Administer a diuretic as prescribed
• D. Assess the client for signs of fluid overload

Correct answer: D

Rationale: The correct first intervention for a client with heart failure who is on a low sodium diet and reports a significant weight gain is to assess the client for signs of fluid overload. This step is crucial in determining the severity of the situation and guiding further treatment. In this scenario, assessing for signs of fluid overload takes priority over other actions such as instructing the client to reduce fluid intake, monitoring intake and output, or administering a diuretic. While these actions may be necessary depending on the assessment findings, the initial priority is to evaluate the client's immediate condition.

2. A client with a history of chronic heart failure is admitted with shortness of breath. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Chest X-ray
• B. Arterial blood gases (ABGs)
• C. Echocardiogram
• D. Electrocardiogram (ECG)

Correct answer: C

Rationale: The correct answer is an echocardiogram. This diagnostic test is crucial in assessing ventricular function and identifying the cause of shortness of breath in a client with heart failure. It provides valuable information about the heart's structure, function, and blood flow. While a chest X-ray may show signs of heart failure, it does not directly assess cardiac function like an echocardiogram does. Arterial blood gases (ABGs) are useful to evaluate oxygenation and acid-base balance but do not provide information specific to heart function. An electrocardiogram (ECG) assesses the heart's electrical activity and rhythm, which is important but may not provide the detailed structural information needed in this scenario.

3. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products. His current blood pressure is 78/52 mm Hg, and he is being mechanically ventilated. His oxygen saturation is 87%. Laboratory values indicate hemoglobin of 7 g/dL, platelets of 20,000/mm³, and white blood cells of 2,000/mm³. 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 above 90%.

Correct answer: A

Rationale: The correct answer is to transfuse packed red blood cells first. The client's low hemoglobin level of 7 g/dL indicates severe anemia, which requires immediate transfusion to increase oxygen-carrying capacity. While obtaining blood and sputum cultures (Choice B) is important to identify potential infections, addressing the critical issue of anemia takes precedence. Infusing normal saline (Choice C) may help with volume status but does not address the primary concern of low hemoglobin. Titration of oxygen (Choice D) is crucial, but transfusion to improve oxygen-carrying capacity should be the priority in this scenario.

4. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Lying flat with legs elevated
• C. Lying on the side with the head slightly raised
• D. Sitting up and tilting the head back

Correct answer: A

Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.

5. A client with acute pancreatitis is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Serum glucose
• C. Serum triglycerides
• D. Serum calcium

Correct answer: C

Rationale: In a client with acute pancreatitis receiving total parenteral nutrition (TPN), the nurse should monitor serum triglycerides closely. Acute pancreatitis can lead to fat malabsorption, making the client susceptible to hypertriglyceridemia. Monitoring serum triglycerides is crucial to prevent complications such as hyperlipidemia. While monitoring serum potassium, glucose, and calcium levels is also essential in various conditions, in this scenario, the primary concern is the risk of developing hypertriglyceridemia due to fat malabsorption.

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