Nursing Elites

1. Which chamber of the heart receives oxygenated blood from the lungs?

• A. Left atrium
• B. Right atrium
• C. Left ventricle
• D. Right ventricle

Correct answer: A

Rationale: The correct answer is A, the left atrium. The left atrium receives oxygenated blood from the lungs through the pulmonary veins. This blood is then pumped into the left ventricle before being circulated throughout the body. The right atrium, represented by choice B, actually receives deoxygenated blood from the body through the vena cava. Choices C and D, the left ventricle and right ventricle respectively, are chambers involved in pumping blood out of the heart to the body and lungs, rather than receiving blood from the lungs.

2. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

• A. Assessment
• B. Diagnosis
• C. Planning
• D. Implementation

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

3. Which of the following measures is not recommended to prevent pressure ulcers?

• A. Massaging the reddened area with lotion
• B. Using a water or air mattress
• C. Adhering to a schedule for positioning and turning
• D. Providing meticulous skin care

Correct answer: A

Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.

4. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

• A. Low back pain.
• B. Dyspnea.
• C. Hypotension.
• D. Thready pulse.

Correct answer: B

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

5. When reviewing the prescriptions for a client with a pneumothorax, which of the following actions should the nurse perform first?

• A. Assess the client's pain.
• B. Obtain a large-bore IV needle for decompression.
• C. Administer lorazepam.
• D. Prepare for chest tube insertion.

Correct answer: B

Rationale: In a client with a pneumothorax, the priority action for the nurse is to obtain a large-bore IV needle for decompression. This intervention helps to relieve the pressure in the pleural space, allowing the lung to re-expand. Prompt decompression is crucial in managing a tension pneumothorax, which can be life-threatening. Assessing pain, administering medication, and preparing for chest tube insertion are important, but they should follow the immediate intervention of decompression in a critical situation like a tension pneumothorax.

Similar Questions