Nursing Elites

1. A client with left-sided heart failure is experiencing dyspnea and orthopnea. Which position should the nurse place the client in to relieve these symptoms?

• A. High Fowler's position.
• B. Supine position.
• C. Trendelenburg position.
• D. Sims' position.

Correct answer: A

Rationale: Placing the client in High Fowler's position is beneficial for individuals with left-sided heart failure experiencing dyspnea and orthopnea. This position helps to reduce venous return, decrease preload, and enhance respiratory function, thereby relieving the symptoms mentioned. Choice B, the supine position, is not recommended as it may exacerbate dyspnea and orthopnea by increasing preload. Choice C, the Trendelenburg position, is incorrect as it involves the feet being positioned higher than the head, which is not suitable for heart failure patients. Choice D, the Sims' position, is a lateral position used for rectal examination and is not indicated for relieving dyspnea and orthopnea in heart failure.

2. The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?

• A. Serum sodium.
• B. Serum potassium.
• C. Serum calcium.
• D. Serum magnesium.

Correct answer: B

Rationale: Furosemide (Lasix) is a loop diuretic that can lead to potassium loss, causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias associated with low potassium levels.

3. A client with coronary artery disease (CAD) is prescribed atorvastatin (Lipitor). Which laboratory value requires immediate intervention?

• A. Total cholesterol of 180 mg/dL.
• B. Low-density lipoprotein (LDL) of 200 mg/dL.
• C. Triglycerides of 150 mg/dL.
• D. High-density lipoprotein (HDL) of 40 mg/dL.

Correct answer: B

Rationale: An LDL level of 200 mg/dL is significantly elevated and requires immediate intervention to reduce the risk of cardiovascular events in a client with coronary artery disease (CAD). High LDL levels contribute to the development and progression of atherosclerosis, which can lead to complications like heart attacks and strokes. Lowering LDL levels is a key goal in managing CAD and preventing further cardiovascular damage. Total cholesterol of 180 mg/dL, triglycerides of 150 mg/dL, and HDL of 40 mg/dL are within acceptable ranges and do not pose an immediate risk that necessitates urgent intervention.

4. A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?

• A. Administer morphine sulfate.
• B. Place the client in a high Fowler's position.
• C. Initiate continuous ECG monitoring.
• D. Prepare the client for intubation.

Correct answer: B

Rationale: In a client with chronic heart failure experiencing severe shortness of breath and pink, frothy sputum, the priority action for the nurse is to place the client in a high Fowler's position. This position helps improve lung expansion, ease breathing, and enhance oxygenation by reducing venous return and decreasing preload on the heart. It is crucial to address the client's respiratory distress promptly before considering other interventions. Administering morphine sulfate (choice A) may be appropriate later to relieve anxiety and reduce the work of breathing, but positioning is the priority. Continuous ECG monitoring (choice C) and preparing for intubation (choice D) are important but secondary to addressing the respiratory distress and optimizing oxygenation.

5. A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: Stage 3 hepatic encephalopathy is characterized by confusion, difficulty arousing from sleep, and rigidity of extremities. These symptoms indicate advanced manifestations of hepatic encephalopathy, requiring prompt intervention and monitoring to prevent further neurological deterioration.

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