Nursing Elites

1. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?

• A. Sputum culture findings
• B. Oxygen saturation level
• C. Amount of coughing
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is A: Sputum culture findings. Reviewing sputum culture findings can provide valuable information to differentiate between bacterial pneumonia and heart failure, as the type of bacteria present in the sputum can help identify the specific infection. Oxygen saturation level (Choice B) is important for assessing oxygenation status but does not directly help in distinguishing between the two conditions based on lung sounds. The amount of coughing (Choice C) and respiratory rate (Choice D) may offer some clinical insights but are not as specific or diagnostic as sputum culture findings when differentiating between heart failure and bacterial pneumonia.

2. A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Observe for bleeding side effects related to heparin therapy.
• B. Assess blood pressure and heart rate at least every 4 hours.
• C. Measure calf girth to evaluate edema in the affected leg.
• D. Encourage mobilization to prevent pulmonary embolism.

Correct answer: A

Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.

3. The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

• A. Low-grade fever
• B. Bruising of the skin
• C. Abdominal cramping
• D. Bloody emesis

Correct answer: D

Rationale: The correct answer is D: Bloody emesis. Bloody emesis indicates potential bleeding or severe irritation, which should be reported immediately. In the context of acute gastritis, bloody emesis could indicate a more serious complication that requires urgent medical attention. Choices A, B, and C are not typically associated with acute gastritis caused by contaminated water and do not signal as critical of a condition as bloody emesis. Low-grade fever, bruising of the skin, and abdominal cramping are more commonly associated with other conditions or may be less urgent in this context.

4. A client with eczema is experiencing severe pruritus. Which PRN prescription should the nurse administer?

• A. Topical corticosteroid
• B. Topical scabicide
• C. Topical alcohol rub
• D. Transdermal analgesic

Correct answer: A

Rationale: The correct answer is A: Topical corticosteroid. Topical corticosteroids are commonly used to manage itching in eczema by reducing inflammation and suppressing the immune response. In this case, for severe pruritus in eczema, a topical corticosteroid would be appropriate. Choice B, Topical scabicide, is used to treat scabies, not eczema. Choice C, Topical alcohol rub, is not typically used to manage pruritus in eczema. Choice D, Transdermal analgesic, is more for pain relief and not specifically targeted at managing itching associated with eczema.

5. After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?

• A. Send the calculi for laboratory analysis of stone composition.
• B. Evaluate the client for persistent pain.
• C. Assess the clarity of urine.
• D. Encourage high fluid intake to produce urine output of 2L/day.

Correct answer: A

Rationale: Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.

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