Nursing Elites

1. While auscultating the anterior chest of a newly admitted patient, what would the nurse expect to hear?

• A. Normal breathing sounds
• B. Wheezing
• C. Crackles
• D. Stridor

Correct answer: A

Rationale: When auscultating the chest, normal breathing sounds are expected in a healthy individual. Wheezing is a high-pitched whistling sound that indicates narrowed airways and is often heard in conditions like asthma. Crackles are fine, crackling sounds heard on inspiration or expiration and are associated with conditions like pneumonia or heart failure. Stridor is a high-pitched, harsh sound heard during inspiration due to upper airway obstruction. Therefore, choices B, C, and D indicate abnormal respiratory findings, while choice A signifies normal breathing sounds.

2. A client with heart failure is being taught by a nurse on reducing daily sodium intake. What is the most important factor in determining the client's ability to learn new dietary habits?

• A. The involvement of the client in planning the change
• B. The presence of a dietitian during the teaching
• C. The use of dietary supplements
• D. The client's family support

Correct answer: A

Rationale: The most crucial factor in the client's ability to learn new dietary habits is their involvement in planning the change. When clients actively participate in setting their dietary goals, they are more likely to commit to and adhere to the changes. This empowerment fosters a sense of ownership and responsibility, enhancing the chances of successful dietary modifications. The presence of a dietitian, use of dietary supplements, and family support, while beneficial, are not as critical as the client's active participation in planning the dietary changes.

3. The nurse is providing care for a client who is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely to assess for complications?

• A. Serum potassium
• B. Blood glucose
• C. Serum sodium
• D. Serum calcium

Correct answer: B

Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the increased risk of hyperglycemia associated with TPN infusion. Elevated blood glucose levels can lead to complications such as hyperglycemia, which can be harmful to the client. While monitoring serum potassium (Choice A), serum sodium (Choice C), and serum calcium (Choice D) are also important aspects of care, when specifically considering TPN administration, blood glucose monitoring takes precedence due to the potential for significant complications related to glucose imbalances.

4. A client has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?

• A. Discard the first voiding.
• B. Keep the urine in a single container on ice.
• C. Include the last voiding in the collection.
• D. Instruct the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

Correct answer: A

Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.

5. When caring for a client prescribed a blood transfusion that parents refuse due to religious beliefs, what should the nurse do?

• A. Examine personal values about the issue.
• B. Proceed with the transfusion if medically necessary.
• C. Refer the issue to the ethics committee.
• D. Administer the blood transfusion without informing the parents.

Correct answer: A

Rationale: When faced with a situation where parents refuse a prescribed treatment due to religious beliefs, the nurse should first examine personal values, understand the client's or family’s beliefs, and respect their rights. Proceeding with the transfusion against the parents' wishes without exploring alternatives or understanding their perspective would violate the principle of respect for autonomy and could damage the therapeutic relationship. Referring the issue to the ethics committee should be considered if a resolution cannot be reached through open communication and negotiation with the family.

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