Nursing Elites

1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. Cough with frothy sputum.
• C. Jugular vein distention.
• D. Dependent edema.

Correct answer: C

Rationale: The correct answer is C: Jugular vein distention. In left-sided heart failure, the left ventricle fails to efficiently pump blood to the body, causing increased pressure in the pulmonary circulation. This increased pressure can lead to symptoms like jugular vein distention, as blood backs up in the pulmonary circulation and causes congestion. Choices A, B, and D are incorrect: Peripheral edema is more commonly associated with right-sided heart failure, cough with frothy sputum is a sign of pulmonary edema which can occur in left-sided heart failure but is not as specific as jugular vein distention, and dependent edema is also more indicative of right-sided heart failure due to fluid retention and increased venous pressure in the systemic circulation.

2. A nurse is caring for a client who is receiving enteral feedings through a nasogastric tube. Which of the following findings should the nurse report to the provider?

• A. Gastric residual of 200 mL or more
• B. pH of gastric contents is 5.0
• C. Bowel sounds are present in all quadrants
• D. Temperature 37.5°C (99.5°F)

Correct answer: A

Rationale: The correct answer is A. A gastric residual of 200 mL or more indicates delayed gastric emptying, which can be a sign of potential complications such as aspiration or intolerance to the enteral feedings. This finding should be reported to the healthcare provider for further evaluation and possible intervention. Choices B, C, and D are within normal limits and do not require immediate reporting. A pH of 5.0 is normal for gastric contents, bowel sounds in all quadrants indicate normal gastrointestinal motility, and a temperature of 37.5°C (99.5°F) is within the normal range.

3. A healthcare provider is assessing a client who is receiving chemotherapy and reports mouth sores. Which of the following findings should the healthcare provider expect?

• A. Dry, cracked lips.
• B. Red, swollen gums.
• C. White patches on the tongue.
• D. Pale, dry mouth.

Correct answer: C

Rationale: White patches on the tongue are a sign of oral candidiasis, a common side effect of chemotherapy. This fungal infection can result in the development of white patches on the tongue. Dry, cracked lips (choice A) are more indicative of dehydration or lack of moisture. Red, swollen gums (choice B) may be a sign of gingivitis or periodontal disease. Pale, dry mouth (choice D) is not typically associated with mouth sores from chemotherapy.

4. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse identify as an indication of the effectiveness of the treatment?

• A. Respiratory rate of 24/min
• B. White blood cell count of 15,000/mm3
• C. SpO2 of 95%
• D. Clear breath sounds

Correct answer: D

Rationale: Clear breath sounds are an essential indicator of effective pneumonia treatment as they suggest resolution of the lung infection. A normal respiratory rate (A) indicates adequate breathing but does not directly reflect the effectiveness of pneumonia treatment. An elevated white blood cell count (B) is a sign of infection and may not decrease immediately with treatment. While maintaining an SpO2 of 95% (C) is crucial for oxygenation, it may not directly indicate the effectiveness of pneumonia treatment.

5. A nurse is providing discharge teaching to a client who has a wound infection. Which of the following information should the nurse include about home care?

• A. Soak the wound in warm water every day
• B. Use hydrogen peroxide to clean the wound
• C. Apply a cold compress to the wound
• D. Keep the wound covered with a dry dressing

Correct answer: D

Rationale: The correct answer is D: 'Keep the wound covered with a dry dressing.' When providing care for a wound infection, it is essential to keep the wound covered with a dry dressing to prevent further contamination and promote healing. Soaking the wound in warm water (choice A) can introduce moisture and increase the risk of infection. Using hydrogen peroxide (choice B) can be too harsh and may slow down the healing process by damaging healthy tissue. Applying a cold compress (choice C) is not typically recommended for wound infections, as it may not provide the necessary environment for healing.

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