Nursing Elites

1. A nurse is caring for a client who has heart failure and a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?

• A. Increased shortness of breath.
• B. Decreased peripheral edema.
• C. Increased jugular venous distention.
• D. Increased heart rate.

Correct answer: B

Rationale: The correct answer is B: Decreased peripheral edema. Furosemide is a diuretic that helps in reducing fluid overload in clients with heart failure by increasing urine output. A decrease in peripheral edema indicates that the medication is effectively removing excess fluid from the body. Choices A, C, and D are incorrect because they do not indicate an improvement in the client's condition. Increased shortness of breath, increased jugular venous distention, and increased heart rate are all signs of worsening heart failure and would not be expected findings when furosemide is effective.

2. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serous drainage at the incision site
• B. Temperature 38.2°C (100.8°F)
• C. Heart rate 92/min
• D. Blood pressure 130/80 mm Hg

Correct answer: B

Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.

3. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

• A. Provide information about stress management.
• B. Maintain a warm temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.

4. A nurse is assessing a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse expect?

• A. Diarrhea
• B. Muscle weakness
• C. Hypertension
• D. Bradycardia

Correct answer: B

Rationale: Muscle weakness is a common finding in clients with hypokalemia, as potassium is essential for proper muscle function. Diarrhea (choice A) is more commonly associated with hyperkalemia rather than hypokalemia. Hypertension (choice C) is not typically a direct result of low potassium levels. Bradycardia (choice D) is more commonly associated with hyperkalemia, not hypokalemia.

5. A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?

• A. Hypnosis focuses on biofeedback as a relaxation technique
• B. Hypnosis promotes increased control of pain perception during contractions
• C. Hypnosis uses therapeutic touch to reduce anxiety during labor
• D. Hypnosis provides instruction to minimize pain

Correct answer: B

Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.

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