Nursing Elites

1. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?

• A. Risk for imbalanced body temperature
• B. Excess fluid volume
• C. Fatigue
• D. Ineffective Tissue Perfusion

Correct answer: D

Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.

2. The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Activated partial thromboplastin time (aPTT)

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). While INR is commonly used to monitor the effectiveness of warfarin therapy, in the case of heparin therapy, the Partial Thromboplastin Time (PTT) is the preferred test. Choice A, Prothrombin Time (PT), measures the activity of the extrinsic pathway of coagulation and is not the best choice for monitoring heparin therapy. Choice D, Activated Partial Thromboplastin Time (aPTT), is similar to PTT and is used to monitor heparin therapy, but PTT is the more specific test. Therefore, monitoring PTT is crucial in determining the effectiveness and safety of heparin therapy.

3. A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?

• A. Use manual pressure to express urine
• B. Perform the Crede maneuver
• C. Apply an external urinary drainage device
• D. Take a warm sitz bath twice a day

Correct answer: B

Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.

4. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. Which intervention is most important for the nurse to include?

• A. Encourage the client to use sunscreen
• B. Apply lotion to the radiated area
• C. Keep the area dry and clean
• D. Encourage the client to exercise the arm

Correct answer: C

Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.

5. In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?

• A. Pink lips and tongue with cyanotic hands and feet
• B. Respiration rate of 40 and heart rate of 144
• C. Centralized cyanosis and tachycardia when crying
• D. Desquamation from areas of cracked, parchment-like skin

Correct answer: C

Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.

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