Nursing Elites

1. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?

• A. A client who is 1 hr postoperative and has hypoactive bowel sounds.
• B. A client who has a fractured left tibia and pallor in the affected extremity.
• C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses.
• D. A client who has an elevated AST level following the administration of azithromycin.

Correct answer: B

Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.

2. What are the complications of untreated DVT?

• A. Pulmonary embolism and stroke
• B. Infection and kidney failure
• C. Hypertension and vision loss
• D. Dehydration and electrolyte imbalance

Correct answer: A

Rationale: The correct answer is A: Pulmonary embolism and stroke. Untreated DVT can result in these serious complications, emphasizing the importance of timely intervention. Choices B, C, and D are incorrect because they do not represent common complications associated with untreated deep vein thrombosis. Infection and kidney failure, hypertension and vision loss, as well as dehydration and electrolyte imbalance are not typically direct consequences of untreated DVT.

3. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Elevated blood glucose.
• B. Decreased urine output.
• C. Dependent edema.
• D. Jaundice.

Correct answer: C

Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.

4. How should a healthcare provider respond to a patient experiencing acute chest pain?

• A. Administer prescribed nitroglycerin
• B. Provide oxygen
• C. Call for emergency assistance
• D. Reassure the patient

Correct answer: A

Rationale: In the case of a patient experiencing acute chest pain, the initial response should include administering prescribed nitroglycerin. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, which can be beneficial in managing chest pain related to cardiac issues. Providing oxygen can also be helpful to support oxygenation. However, the priority in this scenario is to address the potential cardiac cause by administering nitroglycerin. Calling for emergency assistance is crucial if the patient's condition does not improve or deteriorates. Reassuring the patient is essential for emotional support but should not be the primary intervention in the case of acute chest pain.

5. A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?

• A. Offer medical advice
• B. Offer general leads
• C. Ask open-ended questions
• D. Use assertive communication

Correct answer: B

Rationale: In the context of establishing a trusting relationship with a client who has major depressive disorder, offering general leads is the most appropriate communication technique. General leads encourage clients to express themselves by providing subtle prompts or cues, which can help build rapport and trust. Offering medical advice (Choice A) is not suitable as it may come across as imposing and could hinder the establishment of trust. Asking open-ended questions (Choice C) is beneficial for eliciting detailed responses but may not be as effective at initially establishing trust as general leads. Using assertive communication (Choice D) can be perceived as aggressive and intimidating, which is not conducive to building a trusting relationship with a client who has major depressive disorder.

Similar Questions