Nursing Elites

1. A client scheduled for a thoracentesis requires assistance from a nurse. Which of the following actions should the nurse take?

• A. Assist the client to a prone position.
• B. Assist the client to a sitting position.
• C. Assist the client to a supine position.
• D. Assist the client to a lateral position.

Correct answer: B

Rationale: The correct answer is to assist the client to a sitting position. Placing the client in a sitting position helps facilitate easier access during the thoracentesis procedure by allowing gravity to assist in the removal of pleural fluid. Placing the client in a prone, supine, or lateral position would not provide the optimal positioning needed for a thoracentesis and could make the procedure more challenging or uncomfortable for the client.

2. A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?

• A. Dry, hacking cough
• B. Bounding peripheral pulses
• C. Decreased urinary output
• D. Weight loss of 1 kg in 24 hours

Correct answer: C

Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.

3. A client has a new prescription for metoprolol. Which of the following client statements indicates an understanding of the teaching?

• A. I will take this medication with a glass of milk.
• B. I will take my pulse before taking this medication.
• C. I will stop taking this medication if I experience nausea.
• D. I will take an antacid with this medication.

Correct answer: B

Rationale: The correct answer is B. Clients taking metoprolol should regularly check their pulse and should not take the medication if their pulse is too low. Option A is incorrect because metoprolol should not be taken with a glass of milk. Option C is incorrect because stopping medication abruptly can be harmful. Option D is incorrect because antacids should not be taken with metoprolol as they can decrease its absorption.

4. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

• A. Dry mucous membranes
• B. Polyuria
• C. Epistaxis
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

5. A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?

• A. Denial
• B. Bargaining
• C. Acceptance
• D. Anger

Correct answer: B

Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'

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