Nursing Elites

1. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.

2. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 60/min
• B. Respiratory rate of 16/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1.5 kg (3.3 lb) in 24 hours

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

3. How should a healthcare professional assess for infection in a patient post-surgery?

• A. Check the surgical site
• B. Check for fever
• C. Check for abnormal breath sounds
• D. Check the patient's skin color

Correct answer: A

Rationale: When assessing for infection in a patient post-surgery, checking the surgical site is crucial. Changes in the appearance of the surgical site, such as redness, swelling, warmth, or drainage, can indicate an infection. While checking for fever (Choice B) is also important as it can be a sign of infection, it is a more general symptom and may not always be present. Checking for abnormal breath sounds (Choice C) and skin color (Choice D) are not typically direct indicators of infection in a post-surgery patient.

4. A nurse is caring for a client who is receiving radiation therapy for breast cancer. Which of the following skin care instructions should the nurse provide?

• A. Wear loose clothing over the radiation site.
• B. Use scented lotions to moisturize the skin.
• C. Apply ice packs to the radiation site for pain relief.
• D. Expose the radiation site to sunlight for 20 minutes daily.

Correct answer: A

Rationale: The correct answer is A: Wear loose clothing over the radiation site. Clients receiving radiation therapy should wear loose clothing over the treatment area to prevent irritation and promote healing. Choice B is incorrect as scented lotions can irritate the skin during radiation therapy. Choice C is incorrect because ice packs should not be applied to the radiation site as they can exacerbate skin reactions. Choice D is incorrect as exposing the radiation site to sunlight can increase skin damage and should be avoided.

5. A client reports intimate partner violence to a nurse. What is the nurse's priority action?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Ensure the client has access to legal services.

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.

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