Nursing Elites

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

• A. Peripheral edema.
• B. Bradycardia.
• C. Jugular vein distention.
• D. Dependent edema.

Correct answer: C

Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.

2. What is the first action for a healthcare provider when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to 'Assess the patient for injuries' when a patient experiences a fall. This is crucial to promptly identify any injuries and provide appropriate care. Calling for help may be necessary, but assessing the patient's condition takes precedence to ensure immediate attention to any injuries. Documenting the fall and notifying the healthcare provider would follow after the initial assessment and necessary actions have been taken.

3. A nurse is assessing a client who has a peripherally inserted central catheter (PICC). Which of the following findings should the nurse report to the provider?

• A. Redness at the insertion site.
• B. Swelling of the arm above the insertion site.
• C. A bruised area around the insertion site.
• D. A temperature of 37.2°C (99°F).

Correct answer: B

Rationale: Swelling of the arm above the insertion site is concerning as it can indicate complications like thrombosis, which require immediate attention. Redness at the insertion site is common and expected in the initial stages. A bruised area around the insertion site may result from the insertion procedure and is usually not alarming unless it worsens or becomes larger. A temperature of 37.2°C (99°F) is within the normal range and is not directly related to PICC complications.

4. Which of the following lab values indicates a patient on warfarin is at a therapeutic level?

• A. INR of 1.1
• B. PT of 12 seconds
• C. INR of 2.5
• D. Platelet count of 150,000

Correct answer: C

Rationale: An INR of 2.5 indicates a therapeutic level for a patient on warfarin. The INR (International Normalized Ratio) is the most accurate way to monitor and adjust warfarin doses. An INR of 1.1 (Choice A) is below the therapeutic range, indicating a need for an increased dose. PT (Prothrombin Time) of 12 seconds (Choice B) is not specific for warfarin therapy monitoring. Platelet count (Choice D) is not directly related to monitoring warfarin therapy.

5. A nurse is planning care for a client who has dehydration. Which of the following interventions should the nurse include?

• A. Monitor the client's fluid intake.
• B. Provide the client with a high-protein diet.
• C. Encourage the client to ambulate frequently.
• D. Administer 0.45% sodium chloride IV.

Correct answer: D

Rationale: The correct intervention for a client with dehydration is to administer 0.45% sodium chloride IV. This solution helps correct fluid imbalance by providing the necessary electrolytes. Restricting fluid intake (Choice A) is not appropriate for dehydration as the client needs adequate fluids to rehydrate. Providing a high-protein diet (Choice B) is not directly related to correcting dehydration. Encouraging the client to ambulate frequently (Choice C) is beneficial for overall health but does not address the issue of dehydration directly.

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