Nursing Elites

1. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

• A. Expresses an understanding of the procedure.
• B. NPO for 6 hrs.
• C. No known drug allergies.
• D. Intravenous access intact.

Correct answer: A

Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.

2. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?

• A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
• B. A client with a healing surgical wound
• C. A client requiring wound dressing change
• D. A client with stable vital signs needing medication administration

Correct answer: A

Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.

3. The nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
• B. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain.
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

Correct answer: D

Rationale: The correct answer is D. A client who had an abdominal-perineal resection 2 days ago with no drainage on the dressing but is presenting with fever and chills requires immediate attention. This presentation raises concerns for peritonitis, a serious complication that necessitates prompt assessment and intervention to prevent further complications. Choices A, B, and C do not indicate an immediate risk for a life-threatening condition like peritonitis, making them lower priority compared to choice D.

4. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated, and his blood pressure drops to 60/40. Which intervention should the nurse implement?

• A. Administer a second dose of nitroglycerin.
• B. Infuse a rapid IV normal saline bolus.
• C. Begin external chest compressions.
• D. Give a PRN antiemetic medication.

Correct answer: B

Rationale: In this scenario, the client's symptoms of nausea and a significant drop in blood pressure suggest a potential right ventricular infarction. The appropriate intervention for this situation is to infuse a rapid IV normal saline bolus. This fluid resuscitation helps improve cardiac output by increasing preload, which can be beneficial in right ventricular infarction. Administering a second dose of nitroglycerin may further lower blood pressure. External chest compressions are not indicated in this case as the client has a pulse. Providing an antiemetic medication does not address the underlying issue of hypotension and potential right ventricular involvement.

5. The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be monitored closely?

• A. Serum sodium of 135 mEq/L
• B. Serum potassium of 4.5 mEq/L
• C. Serum creatinine of 1.8 mg/dl
• D. Serum glucose of 200 mg/dl

Correct answer: C

Rationale: In a client with left-sided heart failure, monitoring serum creatinine is crucial to evaluate kidney function and fluid balance. Elevated creatinine levels can indicate impaired kidney function, which is common in heart failure due to decreased cardiac output and renal perfusion. Serum sodium levels (choice A) are important but are more closely associated with fluid balance and heart failure exacerbation. Serum potassium (choice B) is also important to monitor, but it is more closely linked to cardiac arrhythmias rather than kidney function. Serum glucose levels (choice D) are significant but are not the priority for monitoring in left-sided heart failure.

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