Nursing Elites

1. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?

• A. Peripheral edema
• B. Tachycardia
• C. Bradycardia
• D. Hypotension

Correct answer: A

Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.

2. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?

• A. Nasal cannula remains in place
• B. Client completes morning care
• C. Client verbalizes breathing improvement after lunch
• D. Client maintains oxygen saturation of 90% during the shift

Correct answer: D

Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.

3. A client is taking levothyroxine. Which of the following findings should indicate that the medication is effective?

• A. Weight loss
• B. Decreased blood pressure
• C. Absence of seizures
• D. Decreased inflammation

Correct answer: A

Rationale: The correct answer is A: Weight loss. Levothyroxine is used to treat hypothyroidism, which is characterized by symptoms such as weight gain. Therefore, weight loss in a client taking levothyroxine indicates that the medication is effective in managing hypothyroidism. Choices B, C, and D are incorrect because levothyroxine primarily affects thyroid function and metabolism, not blood pressure, seizures, or inflammation.

4. While caring for a client receiving oxytocin for labor augmentation, the nurse notes contractions occurring every 45 seconds and lasting 90 seconds. What should the nurse do?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Apply an internal fetal monitor
• D. Administer an analgesic

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, which can lead to fetal distress and complications. By stopping the oxytocin, the nurse can help regulate contractions and prevent harm to the fetus. Increasing the oxytocin infusion would exacerbate the issue by further intensifying contractions. Applying an internal fetal monitor may be necessary for closer monitoring but is not the immediate action required. Administering an analgesic is not appropriate in this scenario as the primary concern is addressing the uterine hyperstimulation caused by oxytocin.

5. A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?

• A. I should reduce my fluid intake to 2 hours before bedtime
• B. I will watch TV in bed before sleeping
• C. I can take long naps during the day
• D. I should exercise right before going to bed

Correct answer: A

Rationale: The correct answer is A. Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep. Watching TV in bed before sleeping (choice B) can actually hinder sleep due to the stimulation from screens. Taking long naps during the day (choice C) can disrupt the natural sleep-wake cycle. Exercising right before going to bed (choice D) can increase alertness and make it harder to fall asleep.

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