Nursing Elites

1. The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

• A. Muscle tetany
• B. Syncope
• C. Numbness
• D. Anxiety

Correct answer: D

Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.

2. After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?

• A. Have the client take slow deep breaths in through their mouth and out through their nose.
• B. Post signs indicating that oxygen is in use on the client’s door and in their room
• C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client’s ears
• D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

Correct answer: Post signs indicating that oxygen is in use on the client’s door and in their room

Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client’s door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.

3. A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?

• A. “You should discuss the inheritance risk with your physician.”
• B. “Sickle cell disease is genetically based and might be passed on to children.”
• C. “Sickle cell disease is genetically based and is not passed on to children.”
• D. “Sickle cell disease is caused by an infection and cannot be passed on to children.”

Correct answer: “Sickle cell disease is genetically based and might be passed on to children.”

Rationale: A client with sickle cell disease has a genetic condition that can be passed on to their offspring. The most appropriate statement for the PN to provide is to acknowledge this fact and inform the client that sickle cell disease is genetically based and might be passed on to children. This empowers the client with accurate information. Choice A has been refined to emphasize discussing the inheritance risk, making it a better option than the vague original choice. Choices C and D provide incorrect information. Sickle cell disease is indeed genetically based and can be inherited.

4. A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?

• A. Lab values of Potassium and Sodium
• B. Lab values of Glucose and Hemoglobin
• C. ECG
• D. CT scan

Correct answer: Lab values of Potassium and Sodium

Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.

5. For a client with suspected appendicitis, where should the nurse expect to find abdominal tenderness?

• A. upper right
• B. upper left
• C. lower right
• D. lower left

Correct answer: lower right

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic symptom of appendicitis. This tenderness is known as McBurney's point, which is located in the lower-right quadrant of the abdomen. Choices A, B, and D are incorrect because the tenderness associated with appendicitis is typically localized to the lower-right quadrant.

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