Nursing Elites

1. The nurse is assisting with the care of a client diagnosed with heart failure. Which finding should the nurse report to the healthcare provider immediately?

• A. Weight gain of 2 pounds in 2 days
• B. Increased urination at night
• C. Mild shortness of breath on exertion
• D. Decreased appetite and fatigue

Correct answer: A

Rationale: A weight gain of 2 pounds in 2 days is concerning in a client with heart failure as it can indicate fluid retention and worsening of the condition. This finding requires immediate medical attention to prevent further complications. Increased urination at night (choice B) may be due to various reasons like diuretic use and is not an immediate concern. Mild shortness of breath on exertion (choice C) is expected in clients with heart failure and may not require immediate reporting. Decreased appetite and fatigue (choice D) are common symptoms in heart failure but are not as urgent as sudden weight gain.

2. The healthcare provider is reviewing the medication orders for a client with angina pectoris. Which medication is typically prescribed to prevent angina attacks?

• A. Aspirin
• B. Nitroglycerin
• C. Atenolol
• D. Simvastatin

Correct answer: B

Rationale: Nitroglycerin is the medication typically prescribed to prevent angina attacks. It works by dilating blood vessels, increasing blood flow, and reducing the heart's workload, hence relieving angina symptoms. Aspirin is often used to prevent blood clots, not specifically to prevent angina attacks. Atenolol is a beta-blocker used to manage high blood pressure and chest pain but is not typically prescribed to prevent angina attacks. Simvastatin is a statin medication primarily used to lower cholesterol levels and is not indicated for preventing angina attacks.

3. A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

• A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
• B. Turn the client prone to apply pressure on the abdominal wound to help staunch the bleeding.
• C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.
• D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Correct answer: C

Rationale: In a client with profuse bleeding from a gunshot wound to the abdomen, maintaining the client in a supine position is essential to manage blood pressure. This position helps in reducing diaphragmatic pressure and allows for proper visualization of the wound, aiding in prompt assessment and intervention to control the bleeding and stabilize the client's condition. Placing the client in a 45-degree Trendelenburg position (Choice A) could worsen the bleeding by increasing intrathoracic pressure and venous return, potentially leading to further hemorrhage. Turning the client prone (Choice B) may not be feasible in this situation and can delay essential interventions. Placing the client on the right side (Choice D) does not address the immediate need to manage the bleeding and stabilize the client's condition.

4. A client with hypertension is prescribed a thiazide diuretic. What instruction should the nurse reinforce to the client?

• A. Take the medication in the morning.
• B. Increase potassium intake in the diet.
• C. Weigh yourself daily.
• D. Limit fluid intake to 2 liters per day.

Correct answer: C

Rationale: The correct answer is to weigh oneself daily. This instruction is important as daily weights help monitor fluid loss and are crucial for detecting early signs of fluid imbalance when taking a diuretic. Weighing daily allows for timely adjustments in treatment and helps prevent complications associated with fluid imbalance. Choice A is not directly related to the client's need for monitoring fluid balance. Choice B, although important for some diuretics, is not specific to thiazide diuretics. Choice D is not appropriate as limiting fluid intake without proper monitoring can lead to dehydration, especially when taking diuretics.

5. The client is reinforcing instructions for a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. I will avoid adding salt to my food while cooking.
• B. I will use salt substitutes instead of regular salt.
• C. I can eat as much processed food as I like since it's usually low in sodium.
• D. I will read food labels to check for sodium content.

Correct answer: C

Rationale: The correct answer is C. Processed foods often contain high amounts of sodium, so they should be limited or avoided on a low-sodium diet. Choosing processed foods can lead to increased sodium intake, counteracting the purpose of following a low-sodium diet. Option A shows an understanding of avoiding added salt, Option B suggests using alternatives to regular salt, and Option D indicates a willingness to check food labels for sodium content, all of which are appropriate for a low-sodium diet. Therefore, the client's statement about eating processed foods freely is incorrect and requires further teaching.

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