Nursing Elites

1. The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Elevated liver enzymes
• D. Elevated blood glucose level

Correct answer: C

Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.

2. The nurse is assessing a client with left-sided heart failure. Which finding is most concerning?

• A. Jugular venous distention
• B. Crackles in the lungs
• C. Shortness of breath
• D. Peripheral edema

Correct answer: C

Rationale: Shortness of breath is most concerning in a client with left-sided heart failure as it indicates pulmonary congestion, requiring immediate intervention. Jugular venous distention (Choice A) is a sign of increased central venous pressure but is not as concerning as pulmonary congestion. Crackles in the lungs (Choice B) are common in heart failure due to fluid accumulation but are not as immediately concerning as severe shortness of breath. Peripheral edema (Choice D) is a manifestation of fluid retention in the body but is less indicative of acute pulmonary distress compared to shortness of breath.

3. A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effects, he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse?

• A. Anxiety and restlessness
• B. Increased bowel movements
• C. Abdominal cramping
• D. Fever and chills

Correct answer: A

Rationale: The correct answer is A: Anxiety and restlessness. Abruptly stopping corticosteroids can cause adrenal insufficiency, leading to symptoms such as anxiety and restlessness. These symptoms indicate a potential serious complication that requires immediate intervention. Increased bowel movements and abdominal cramping are common side effects of ulcerative colitis and may not warrant immediate intervention. Fever and chills are not typically associated with adrenal insufficiency caused by corticosteroid withdrawal.

4. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which laboratory value should be closely monitored?

• A. Serum creatinine of 2.0 mg/dL
• B. Serum sodium of 135 mEq/L
• C. Serum potassium of 5.5 mEq/L
• D. Blood glucose of 150 mg/dL

Correct answer: C

Rationale: A serum potassium level of 5.5 mEq/L should be closely monitored in a client with chronic heart failure as it may indicate hyperkalemia, requiring intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias in patients with heart failure. Serum creatinine (Choice A) is important to monitor for kidney function but is not the priority in this case. Serum sodium (Choice B) and blood glucose (Choice D) levels are not typically the primary focus when assessing a client with heart failure presenting with respiratory symptoms and crackles in the lungs.

5. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding requires immediate intervention?

• A. Increased fatigue
• B. Elevated blood pressure
• C. Headache
• D. Elevated hemoglobin

Correct answer: A

Rationale: The correct answer is A, 'Increased fatigue.' In a client with CKD receiving erythropoietin therapy, increased fatigue can be a sign of polycythemia, a condition characterized by an elevated red blood cell count. This can lead to increased blood viscosity and raise the risk of thromboembolic events, necessitating immediate intervention. Elevated blood pressure (choice B) is a common concern in CKD but does not require immediate intervention in this context. Headache (choice C) may be related to elevated blood pressure but is not the most critical finding requiring immediate attention. Elevated hemoglobin (choice D) is an expected outcome of erythropoietin therapy and does not require immediate intervention unless excessively high.

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