Nursing Elites

1. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

• A. The client with three (3) unifocal PVCs in a minute
• B. The client diagnosed with coronary artery disease who wants to ambulate
• C. The client diagnosed with mitral valve prolapse with an audible S3
• D. The client diagnosed with pericarditis who is in normal sinus rhythm

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure and requires immediate assessment. Choice A is not as urgent as an audible S3 in mitral valve prolapse. Choice B, a client with coronary artery disease wanting to ambulate, does not present an immediate concern compared to a potential heart failure indicated by an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable and does not require immediate attention when compared to a potential heart failure situation signified by an audible S3 in mitral valve prolapse.

2. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.

3. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

• A. Measuring and recording fluid intake and output
• B. Weighing the client daily at the same time each day
• C. Assessing the client’s vital signs every 4 hours
• D. Checking the client’s lungs for crackles during every shift

Correct answer: B

Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.

4. For a patient on lithium therapy, which dietary recommendation is essential?

• A. Increase caffeine intake
• B. Increase sodium intake
• C. Increase protein intake
• D. Increase fiber intake

Correct answer: B

Rationale: The correct answer is to increase sodium intake. For patients on lithium therapy, maintaining consistent sodium intake is crucial to avoid fluctuations in drug levels. Increasing caffeine intake (choice A) is not recommended as it can interfere with lithium levels. While protein intake (choice C) is important for overall health, it is not specifically essential for patients on lithium therapy. Similarly, increasing fiber intake (choice D) is beneficial but not a primary concern for patients on lithium therapy.

5. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of 'Recommend awards and promotions'?

• A. Accountability
• B. Personal/professional development
• C. Individual training
• D. Military appearance/physical condition

Correct answer: A

Rationale: The correct answer is A: 'Accountability.' Accountability involves recommending awards and promotions as part of managing personnel. This responsibility revolves around assessing employee performance and recognizing achievements through awards and promotions. Choice B, 'Personal/professional development,' focuses on enhancing employees' skills and knowledge, not specifically related to recommending awards or promotions. Choice C, 'Individual training,' pertains to providing instruction and guidance to improve specific skills, not directly linked to awarding or promoting individuals. Choice D, 'Military appearance/physical condition,' deals with maintaining physical standards and presentation, unrelated to recommending awards and promotions.

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