Nursing Elites

1. 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.

2. The nurse is caring for a client with a chest tube following a pneumothorax. Which finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Drainage of 50 ml per hour

Correct answer: C

Rationale: Subcutaneous emphysema is the most critical finding requiring immediate intervention in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, which can lead to respiratory compromise. Oxygen saturation of 94% is slightly low but may not require immediate intervention. Crepitus around the insertion site can be a normal finding post-procedure. Drainage of 50 ml per hour is within the expected range for a chest tube output and does not indicate an immediate concern.

3. A client with a history of hypertension is admitted with shortness of breath and chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Pulmonary function tests (PFTs)
• D. Arterial blood gases (ABGs)

Correct answer: A

Rationale: The correct answer is A: Electrocardiogram (ECG). An ECG should be performed first to assess for cardiac ischemia in a client presenting with shortness of breath and chest pain. This test helps in evaluating the electrical activity of the heart and can identify signs of myocardial infarction or other cardiac issues. Choice B, Chest X-ray, may be ordered after the ECG to assess for pulmonary conditions like pneumonia or effusions. Choice C, Pulmonary function tests (PFTs), are used to evaluate lung function and are not the primary diagnostic tests for a client with symptoms of cardiac origin. Choice D, Arterial blood gases (ABGs), may provide information about oxygenation but are not the initial test indicated for a client with suspected cardiac issues.

4. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?

• A. Support the client by praising her progress.
• B. Ask the client if she has had any recent thoughts of harming herself.
• C. Reassure the client about the effectiveness of antidepressant drugs.
• D. Advise the client to keep her belongings for discharge.

Correct answer: B

Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.

5. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beats/minute. What action should the charge nurse implement?

• A. Instruct the UAP to count the client's apical pulse rate for sixty seconds.
• B. Determine if the UAP also measured the client's capillary refill time.
• C. Assign a practical nurse (LPN) to determine if an apical-radial pulse deficit is present.
• D. Notify the healthcare provider of the abnormal pulse rate and pulse volume.

Correct answer: C

Rationale: The correct action for the charge nurse to implement in this situation is to assign a practical nurse (LPN) to determine if an apical-radial pulse deficit is present. This helps to confirm the accuracy of the reported weak pulse. In this scenario, it is crucial to involve a licensed nurse to further assess the situation and provide a more comprehensive evaluation. Inaccurate pulse readings can lead to inappropriate interventions or unnecessary alarm. Instructing the UAP to count the apical pulse may not address the accuracy issue. Checking capillary refill time is not directly related to confirming the weak pulse rate. Notifying the healthcare provider immediately may be premature without confirming the accuracy of the pulse reading first.

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