Nursing Elites

1. The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?

• A. Peripheral edema
• B. Jugular vein distention
• C. Shortness of breath
• D. Weight gain

Correct answer: C

Rationale: Shortness of breath is a characteristic symptom of left-sided heart failure. In this condition, the heart's inability to effectively pump blood forward causes blood to back up into the lungs, leading to fluid accumulation. This fluid accumulation results in pulmonary congestion, manifesting as shortness of breath or difficulty breathing. Peripheral edema (choice A) is more commonly associated with right-sided heart failure, where fluid accumulates in the extremities. Jugular vein distention (choice B) is a sign of increased central venous pressure and is more indicative of right-sided heart failure. Weight gain (choice D) can be a general symptom of heart failure due to fluid retention, but shortness of breath is specifically related to left-sided heart failure.

2. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete.
• B. Take all prescribed medications as directed.
• C. Schedule a follow-up appointment with the healthcare provider.
• D. Wear a mask when in public places.

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

3. During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?

• A. Engage the client in a quiet activity
• B. Provide a structured environment with minimal stimulation
• C. Monitor the client continuously
• D. Adjust the lighting and noise levels

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.

4. Before administration of a stat dose of potassium chloride IV for a client with hypokalemia, what is the most important action for the nurse?

• A. Ensure the IV is flowing freely
• B. Mix the medication thoroughly
• C. Check the client’s electrolyte levels
• D. Obtain a baseline ECG

Correct answer: A

Rationale: The most crucial action for the nurse before administering a stat dose of potassium chloride IV to a client with hypokalemia is to ensure the IV is flowing freely. A freely flowing IV is essential to safely and effectively deliver potassium chloride, helping to prevent infusion-related issues. Checking the client's electrolyte levels or obtaining a baseline ECG may be important but are not the most critical actions before administering the medication. Mixing the medication thoroughly is not applicable in this scenario as potassium chloride is typically provided ready to use.

5. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?

• A. Encourage joining a support group for emotional support
• B. Discuss the possibility of a cure in the future
• C. Suggest focusing on positive aspects of their life
• D. Validate their feelings and listen to their concerns

Correct answer: D

Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.

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