Nursing Elites

1. A parent of a child who is terminally ill tells a nurse that she wants to take her child home. Which of the following responses should the nurse make?

• A. Your provider will be here later today.
• B. I can give you information on what that would involve.
• C. I understand how you feel. I felt the same way when my sister was terminally ill.
• D. I think you should speak with social services about your request.

Correct answer: B

Rationale: The nurse should offer to explain the process of taking the child home and provide resources for the parent's decision. Choice B is the best response as it shows willingness to support the parent by offering information on what taking the child home would involve. Choices A, C, and D do not directly address the parent's request or provide the necessary information and support needed in this situation.

2. What are the clinical manifestations of left-sided heart failure, and how do they differ from right-sided heart failure?

• A. Jugular venous distention and hepatojugular reflex
• B. Hepatomegaly, ascites, and peripheral edema
• C. Dyspnea, cough, and orthopnea
• D. Pulmonary congestion and fatigue

Correct answer: A

Rationale: The correct answer is A. Clinical manifestations of left-sided heart failure include pulmonary symptoms such as dyspnea, cough, and orthopnea. However, left-sided heart failure can also manifest as jugular venous distention and hepatojugular reflex due to the backflow of blood into the pulmonary circulation. Right-sided heart failure is characterized by systemic symptoms like hepatomegaly, ascites, and peripheral edema. Choice B is incorrect as it presents manifestations of right-sided heart failure. Choice C includes symptoms of left-sided heart failure. Choice D describes pulmonary congestion, which is more specific to left-sided heart failure, but it does not encompass the full range of clinical manifestations for left-sided heart failure.

3. A nurse manager notices a discrepancy in a nurse's narcotics record. What is the appropriate action?

• A. Ask the nurse for clarification about the record.
• B. Report the discrepancy to the pharmacy.
• C. Report the issue to the nurse manager immediately.
• D. Ignore the discrepancy as a clerical error.

Correct answer: B

Rationale: The appropriate action when a nurse manager notices a discrepancy in a nurse's narcotics record is to report the discrepancy to the pharmacy. Reporting such discrepancies is crucial to ensure accountability and patient safety. Choice A is incorrect because the nurse manager should not confront the nurse directly without proper investigation. Choice C is incorrect because reporting to the nurse manager may not address the issue effectively. Choice D is incorrect because ignoring the discrepancy can compromise patient safety and violates protocols.

4. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?

• A. Check for signs of deep vein thrombosis.
• B. Assess for compartment syndrome.
• C. Increase the patient's fluid intake.
• D. Prepare the patient for surgery to relieve pain.

Correct answer: B

Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.

5. A client reports pain and swelling at the IV site. What should the nurse do first?

• A. Flush the IV line and continue the infusion.
• B. Stop the infusion and notify the healthcare provider.
• C. Increase the IV infusion rate to reduce discomfort.
• D. Apply a warm compress to the IV site and continue monitoring.

Correct answer: B

Rationale: The correct answer is B: Stop the infusion and notify the healthcare provider. Pain and swelling at an IV site can indicate infiltration or infection, which are serious complications. Stopping the infusion helps prevent further harm to the client, and notifying the healthcare provider promptly allows for appropriate assessment and intervention. Choice A is incorrect because flushing the IV line and continuing the infusion could exacerbate the issue. Choice C is incorrect as increasing the IV infusion rate is not the appropriate action for pain and swelling at the site. Choice D is incorrect because applying a warm compress may not address the underlying issue of infiltration or infection; it's crucial to stop the infusion and seek further guidance.

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