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. The healthcare provider is caring for a client with a chest tube following a pneumothorax. Which assessment finding should be reported to the healthcare provider immediately?

• A. Continuous bubbling in the water seal chamber
• B. Absence of drainage in the collection chamber
• C. Tidaling in the water seal chamber
• D. Presence of subcutaneous emphysema around the insertion site

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber should be reported to the healthcare provider immediately. This finding may indicate an air leak, which can compromise the effectiveness of the chest tube in re-expanding the lung. Absence of drainage in the collection chamber (choice B) may signify that the chest tube is blocked, but it does not pose an immediate threat to the client's condition. Tidaling in the water seal chamber (choice C) is an expected finding and indicates proper functioning of the chest tube system. Presence of subcutaneous emphysema around the insertion site (choice D) suggests air leakage but is not as urgent as continuous bubbling in the water seal chamber.

3. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?

• A. Place tape from the cheek to the forehead
• B. Secure tape from the nose to the ear
• C. Attach tape from the lower eyelid to the upper forehead
• D. Use circular bandaging around the head

Correct answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

4. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. What is the primary purpose of this medication?

• A. To lower blood pressure
• B. To improve appetite
• C. To increase red blood cell production
• D. To reduce fluid retention

Correct answer: C

Rationale: The correct answer is C: 'To increase red blood cell production.' Erythropoietin stimulates the production of red blood cells to treat anemia associated with CKD. Choices A, B, and D are incorrect because erythropoietin therapy is primarily used to address anemia by increasing the production of red blood cells rather than lowering blood pressure, improving appetite, or reducing fluid retention.

5. A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?

• A. Hyperkalemia.
• B. Hyponatremia.
• C. Hypocalcemia.
• D. Hypokalemia.

Correct answer: D

Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.

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