Nursing Elites

1. A nurse is assessing a client who has chronic heart failure. Which of the following findings indicates that the client is experiencing fluid overload?

• A. Increased urine output
• B. Bounding peripheral pulses
• C. Weight loss
• D. Decreased heart rate

Correct answer: B

Rationale: In clients with chronic heart failure, bounding peripheral pulses are a classic sign of fluid overload. This occurs due to increased volume in the arterial system, causing a forceful pulse. Increased urine output (Choice A) is often seen in clients with fluid volume deficit, not overload. Weight loss (Choice C) is also inconsistent with fluid overload as it suggests a fluid deficit. Decreased heart rate (Choice D) is more commonly associated with conditions like bradycardia, hypothyroidism, or the use of certain medications, but not specifically indicative of fluid overload in chronic heart failure.

2. What is the first action for a healthcare provider when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to 'Assess the patient for injuries' when a patient experiences a fall. This is crucial to promptly identify any injuries and provide appropriate care. Calling for help may be necessary, but assessing the patient's condition takes precedence to ensure immediate attention to any injuries. Documenting the fall and notifying the healthcare provider would follow after the initial assessment and necessary actions have been taken.

3. A nurse is caring for a client who has a nasogastric tube in place. Which of the following actions should the nurse take to prevent aspiration?

• A. Elevate the head of the bed 45 degrees during feedings.
• B. Place the client in the left lateral position for 30 minutes after feedings.
• C. Flush the tube with 30 mL of sterile water before each feeding.
• D. Check gastric residuals every 8 hours.

Correct answer: A

Rationale: The correct action to prevent aspiration in a client with a nasogastric tube is to elevate the head of the bed to 45 degrees during feedings. This positioning helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the client in the left lateral position after feedings does not directly prevent aspiration. Flushing the tube with sterile water before each feeding is important for tube patency but does not specifically prevent aspiration. Checking gastric residuals every 8 hours is necessary to monitor the client's tolerance to feedings but is not a direct preventive measure against aspiration.

4. A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

• A. WBC 4,500/mm3
• B. Hemoglobin 12 g/dL
• C. Platelet count 250,000/mm3
• D. Platelet count 100,000/mm3

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm3 is lower than the normal range, indicating thrombocytopenia, which is concerning in clients receiving chemotherapy. Thrombocytopenia can lead to an increased risk of bleeding and bruising. Choices A, B, and C fall within the normal range and would not be a cause for concern in a client receiving chemotherapy.

5. A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?

• A. Keep calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit IV exposure to light.
• D. Attach an inline filter to the IV tubing.

Correct answer: C

Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.

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