Nursing Elites

1. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?

• A. Heart rate
• B. Respiratory status
• C. Blood glucose levels
• D. Liver function

Correct answer: B

Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.

2. A healthcare provider is assessing a client with congestive heart failure. Which of the following signs should the healthcare provider monitor?

• A. Peripheral edema
• B. Decreased appetite
• C. Fatigue
• D. All of the above

Correct answer: D

Rationale: Correct! In a client with congestive heart failure, peripheral edema, decreased appetite, and fatigue are important signs to monitor as they can indicate worsening heart failure. Peripheral edema is a common sign of fluid retention due to the heart's inability to pump effectively, decreased appetite may indicate worsening heart function, and fatigue can be a result of inadequate cardiac output. Monitoring all these signs is crucial for early intervention and management. Choices A, B, and C are incorrect because monitoring only one symptom may not provide a comprehensive assessment of the client's condition.

3. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Perform palpation before auscultation
• B. Perform percussion before auscultation
• C. Perform palpation after auscultation
• D. Perform inspection after auscultation

Correct answer: C

Rationale: The correct answer is C: Perform palpation after auscultation. When conducting an abdominal assessment, the correct sequence is inspection, auscultation, percussion, and then palpation. Inspecting the abdomen allows the nurse to observe any visible abnormalities, followed by listening for bowel sounds during auscultation. Percussion helps assess the density of abdominal contents before palpation for tenderness, masses, or organ enlargement. Choices A, B, and D are incorrect because palpation should always come last in the sequence of an abdominal assessment.

4. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?

• A. Restrict protein intake to less than 40 g/day
• B. Initiate seizure precautions for the client
• C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
• D. Encourage the client to ambulate twice per day

Correct answer: B

Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.

5. A nurse is teaching a client about the use of sildenafil. Which of the following should be included?

• A. It should not be taken with nitrates
• B. Monitor for headaches
• C. It is a prescription medication
• D. It may have side effects

Correct answer: B

Rationale: The correct answer is to monitor for headaches when taking sildenafil. This medication can cause headaches and other side effects, so it is crucial to inform clients about these potential adverse reactions. Choice A is incorrect because sildenafil should not be taken with nitrates due to the risk of severe hypotension. Choice C is incorrect as sildenafil is a prescription medication, not an over-the-counter one. Choice D is incorrect because sildenafil, like any medication, can have side effects that should be discussed with the client.

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