Nursing Elites

1. The nurse is assessing a client with left-sided heart failure. Which clinical finding requires immediate intervention?

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

Correct answer: C

Rationale: Corrected Rationale: In a client with left-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention to prevent worsening heart failure symptoms and respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure but are not as critical as crackles in the lungs because they may indicate fluid overload or right-sided heart failure, which are important to address but not as urgently as managing pulmonary congestion.

2. When administering ceftriaxone sodium (Rocephin) intravenously to a client, what finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched sound that indicates airway obstruction. When administering ceftriaxone sodium (Rocephin) intravenously, if the client develops stridor, it is a medical emergency requiring immediate intervention to maintain a patent airway. Nausea, headache, and pruritus are important to assess, but they do not pose an immediate threat to the client's airway and would not require the same level of urgent intervention as stridor.

3. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer a loop diuretic as prescribed.
• C. Administer intravenous morphine as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.

4. The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?

• A. Wait 1 minute and palpate the systolic pressure before auscultating again.
• B. Increase the inflation pressure by 20 mm Hg and measure again.
• C. Switch to a larger cuff and repeat the measurement.
• D. Document the finding as normal.

Correct answer: A

Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.

5. A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Apical pulse of 58 beats per minute
• C. Presence of a new murmur
• D. Blood pressure of 100/60 mmHg

Correct answer: C

Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.

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