Nursing Elites

1. A healthcare professional is assessing a client with left-sided heart failure. Which finding is most commonly associated with this condition?

• A. Peripheral edema
• B. Jugular vein distention
• C. Hepatomegaly
• D. Crackles in the lungs

Correct answer: D

Rationale: Crackles in the lungs are commonly associated with left-sided heart failure due to pulmonary congestion. Left-sided heart failure leads to the backup of blood into the lungs, causing fluid leakage into the alveoli, which results in the characteristic crackling sound upon auscultation.

2. When planning care, what factors should the nurse consider when utilizing evidence-based practice (EBP)? (Select ONE that does not apply)

• A. Cost-saving measures
• B. Nurse's expertise
• C. Client preferences
• D. Research findings

Correct answer: A

Rationale: In evidence-based practice (EBP), nurses should consider the current evidence (research findings), client preferences, and the nurse's expertise when planning care. By integrating these factors, nurses can provide individualized, effective, and patient-centered care that aligns with the best available evidence, the patient's values, and the nurse's clinical knowledge and experience.

3. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

• A. Raise the foot of the bed to a 90° angle
• B. Remove the dressing to inspect the wound
• C. Prepare to insert a central line
• D. Administer oxygen via nasal cannula

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

4. During an assessment, an older adult client's son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

• A. Bradycardia
• B. Night sweats
• C. Confusion
• D. Narrowed pulse pressure

Correct answer: C

Rationale: Confusion is a common manifestation of pneumonia in older adults. It can result from inadequate oxygenation to the brain due to respiratory compromise. Bradycardia, night sweats, and narrowed pulse pressure are not typically specific findings associated with pneumonia and should be further assessed or monitored, but confusion is a key indicator that warrants immediate attention.

5. The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?

• A. Increase the setting on the suction.
• B. Notify the provider immediately.
• C. Re-position the chest tube.
• D. Take the tubing apart to assess for clots.

Correct answer: B

Rationale: If the drainage from the chest tube decreases significantly, it may indicate a blockage by a clot, potentially leading to cardiac tamponade. The nurse's priority action should be to notify the healthcare provider immediately for further evaluation and intervention. Increasing suction, re-positioning the chest tube, or disassembling the tubing independently are not appropriate actions without healthcare provider guidance in this situation.

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