Nursing Elites

1. What are the clinical manifestations of left-sided heart failure, and how do they differ from right-sided heart failure?

• A. Jugular venous distention and hepatojugular reflex
• B. Hepatomegaly, ascites, and peripheral edema
• C. Dyspnea, cough, and orthopnea
• D. Pulmonary congestion and fatigue

Correct answer: A

Rationale: The correct answer is A. Clinical manifestations of left-sided heart failure include pulmonary symptoms such as dyspnea, cough, and orthopnea. However, left-sided heart failure can also manifest as jugular venous distention and hepatojugular reflex due to the backflow of blood into the pulmonary circulation. Right-sided heart failure is characterized by systemic symptoms like hepatomegaly, ascites, and peripheral edema. Choice B is incorrect as it presents manifestations of right-sided heart failure. Choice C includes symptoms of left-sided heart failure. Choice D describes pulmonary congestion, which is more specific to left-sided heart failure, but it does not encompass the full range of clinical manifestations for left-sided heart failure.

2. After placing the patient back in bed, what should the nurse do next?

• A. Re-assess the patient.
• B. Complete an incident report.
• C. Notify the health care provider.
• D. Do nothing, no harm has occurred.

Correct answer: C

Rationale: After placing the patient back in bed, the nurse should notify the health care provider. This is important because the health care provider needs to be informed of the incident and assess the patient further to ensure no underlying injuries or issues exist. Re-assessing the patient is crucial but notifying the health care provider takes precedence in this situation. Completing an incident report is important for documentation purposes but not the immediate next step. Doing nothing is incorrect as there was an incident involving a fall that needs further evaluation.

3. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?

• A. Check for signs of deep vein thrombosis.
• B. Assess for compartment syndrome.
• C. Increase the patient's fluid intake.
• D. Prepare the patient for surgery to relieve pain.

Correct answer: B

Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.

4. A nurse is completing an assessment of a recently widowed older adult client. He states he is unable to drive and is afraid to cook on the stove. Which of the following community resources should the nurse recommend?

• A. Hospice care
• B. Meals on Wheels
• C. Home health services
• D. American Association of Retired Persons

Correct answer: B

Rationale: The correct answer is B: Meals on Wheels. Meals on Wheels is a community resource that provides food for older adults who are unable to cook for themselves, promoting independence and ensuring proper nutrition. Hospice care (choice A) focuses on providing comfort and support for individuals with life-limiting illnesses; it is not primarily aimed at providing meals. Home health services (choice C) typically involve skilled nursing care and therapy services provided in the home setting, rather than meal delivery. The American Association of Retired Persons (choice D) offers advocacy, support, and resources for older adults but does not directly address the specific needs mentioned in the client's situation.

5. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?

• A. Apply a dressing to the ulcer.
• B. Reposition the patient every 2 hours.
• C. Provide the patient with pain medication.
• D. Clean the ulcer with normal saline.

Correct answer: B

Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.

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