Nursing Elites

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

• A. Jugular venous distention
• B. Peripheral edema
• C. Crackles in the lungs
• D. Elevated liver enzymes

Correct answer: C

Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.

2. The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin). Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Prothrombin time (PT)
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation to prevent complications such as bleeding or clotting. Choices A, B, and D are incorrect. While monitoring electrolyte levels like serum potassium and sodium is important in overall client care, they are not specific to monitoring the effects of warfarin therapy. Prothrombin time (PT) is a component of INR and helps in monitoring warfarin therapy, but INR gives a standardized result that is independent of the laboratory method used, making it the preferred choice for monitoring warfarin therapy.

3. A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 liters per minute.
• B. Instruct the client to rest until the oxygen saturation improves.
• C. Discontinue ambulation and return the client to bed.
• D. Encourage the client to breathe more deeply.

Correct answer: C

Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.

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

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

Correct answer: C

Rationale: Shortness of breath is the most concerning finding in a client with left-sided heart failure as it indicates worsening pulmonary congestion and impaired gas exchange. This symptom suggests that the client is experiencing significant difficulty in breathing and inadequate oxygenation, requiring immediate intervention. Jugular venous distention (Choice A) is often seen in right-sided heart failure, while peripheral edema (Choice B) and crackles in the lungs (Choice D) are common manifestations of left-sided heart failure but are not as acutely concerning as severe shortness of breath, which can rapidly progress to respiratory distress if not addressed promptly.

5. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment 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, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.

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