Nursing Elites

1. What are the early signs of heart failure in a patient?

• A. Shortness of breath and weight gain
• B. Fatigue and chest pain
• C. Nausea and vomiting
• D. Cough and elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. Early signs of heart failure typically manifest as shortness of breath due to fluid accumulation in the lungs and weight gain due to fluid retention in the body. Choices B, C, and D are incorrect. Fatigue and chest pain are symptoms commonly associated with heart conditions but are not specific early signs of heart failure. Nausea and vomiting are not typically early signs of heart failure. Cough can be a symptom of heart failure, but it is usually associated with other symptoms like shortness of breath rather than being an isolated early sign. Elevated blood pressure is not an early sign of heart failure; in fact, heart failure is more commonly associated with low blood pressure.

2. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

3. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

• A. I will let the client know that I am available as the interpreter.
• B. I will receive a small fee for interpreting for this client.
• C. I am glad I am available today, but when I am not, you can use a family member.
• D. I will let the client know that an interpreter is unavailable during the night shift.

Correct answer: A

Rationale: Choice A is correct because the nurse should inform the client of their availability to interpret, ensuring that communication is clear and culturally appropriate. Choice B is incorrect as interpreters in healthcare settings usually do not receive fees for providing interpretation services. Choice C is incorrect because suggesting the use of a family member as an interpreter may not ensure accurate communication, as they may not be trained or impartial. Choice D is incorrect because stating that an interpreter is unavailable during the night shift does not address the current situation where the nurse has agreed to interpret for the client.

4. Which of the following is an early indicator that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Hypotension
• C. Irritability
• D. Confusion

Correct answer: C

Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.

5. How should a healthcare provider assess a patient with sepsis?

• A. Monitor vital signs and administer fluids
• B. Monitor for fever and administer antibiotics
• C. Check for tachycardia and elevated white blood cell count
• D. Administer fluids and provide nutritional support

Correct answer: A

Rationale: In sepsis, it is crucial to monitor vital signs to assess the patient's condition and administer fluids to maintain circulation. This approach helps in stabilizing blood pressure and perfusion. While monitoring for fever and administering antibiotics (choice B) is important in managing sepsis, the initial priority lies in assessing and stabilizing the patient's hemodynamic status. Checking for tachycardia and elevated white blood cell count (choice C) can be part of the assessment but does not encompass the immediate intervention needed in sepsis. Administering fluids and providing nutritional support (choice D) are essential in managing sepsis, but the primary step should be to assess the patient's condition through vital sign monitoring.

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